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Blue Cross Blue Shield of Michigan Analyst- Coding/Billing in Detroit, Michigan

Description

Responsible for assisting and supporting management in the evaluation, recommendation, establishment, implementation and analysis of new and improved production workflows, work processes for systems, reporting and new products/programs to improve customer service levels and overall quality.

  • Support the development, coordination, and implementation of projects to enhance the overall efficiency of operational procedures, methods, controls, and performance.
  • Compile and analyze operational data to identify and resolve business problems.
  • Utilize and maintain available reporting systems. Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the updated process.
  • Provide leadership team with status updates on projects and issues.
  • Communicate and recommend policy changes to achieve project objectives. Assist in documenting departmental procedures.
  • Create and present reports and presentations to display operational data and propose business changes.
  • Provide support to both internal departments and external entities by answering questions, supplying information and training.
  • Participate on special projects or workgroups as assigned.
Qualifications
  • Bachelor's Degree in a related field is preferred.
  • Two (2) years of experience in a related field is required.
  • Effective verbal, written communication and interpersonal skills.
  • Ability to work independently or in a team environment and interact with all levels of the organization.
  • Effective analytical and problem-solving skills to identify, evaluate, recommend and implement changes to processes or procedures to address problems and improve departmental effectiveness.
  • Organizational skills and ability to prioritize; must be able to coordinate multiple activities with varying timelines.
  • Proficient in Microsoft Office suites.
  • Ability to develop and maintain effective working relationships.

  • Bachelor's Degree in a related field is preferred.

  • Two (2) years of experience in a related field is required.
  • Effective verbal, written communication and interpersonal skills.
  • Ability to work independently or in a team environment and interact with all levels of the organization.
  • Effective analytical and problem-solving skills to identify, evaluate, recommend and implement changes to processes or procedures to address problems and improve departmental effectiveness.
  • Organizational skills and ability to prioritize; must be able to coordinate multiple activities with varying timelines.
  • Proficient in Microsoft Office suites.
  • Ability to develop and maintain effective working relationships.

Department Specifics:

Will be responsible for processing of appeal requests related to clinical editing– clinical editing denials, multi-surgery and daily limit processing (dlp) in accord with departmental procedures, including verification of eligibility of member, validity of claim, appeal submitted within timeframes, submission of required documentation. Maintenance of documentation, including completion of logs and database, Maccess, FACETS entry, letter generation, etc., related to appeals and inquiries. Analysis of reports, appeals and inquiries, related to clinical edits, dlp and clinical editing activities. Coordination with BCN Medical Directors to resolve appeals that require medical director intervention. Handling and resolution of inquiries from sources, primarily internal – ensuring consistent application of clinical editing criteria and explanation of same.

  • ICD 10-CM and CPT courses; may consider two years experience with these manuals in lieu of classes.
  • Coding certification preferred (eg, CPC certification)

  • Knowledge of CCI (Correct Coding Initiative) and Medicare reimbursement guidelines are preferred

  • Associate’s Degree in business or health care related field preferred

  • Three (3) years related experience in managed care operations including specific functional experience related to assigned department.

  • Knowledge of NCQA, CMS, State and Federal HMO regulations preferred

  • Minimum of four years in any combination of the following:

Billing and coding experience (preferably in a comprehensive surgical center or facility) or Claims resolution (including adjudication, coding, thorough analysis and problem-solving)

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

Job: Operations

Primary Location: Southfield

Organization: Claims, Enrollment & Prog Mgt-7108

Schedule: Full-time

Req ID: CLI000RH

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