Provider Reimbursement Policy Specialist

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities

Provide subject matter expertise in medical policy and coding: CMS, State Medicaid Agency, AMA CPT, HCPCS, ICD procedures and guidelines. Translate health care benefits to the CPT, HCPCS code level to support Configuration, Provider Contracting, Delegated Sub-contractor implementation, Medical Economics reporting or other internal processes. Interact with payment integrity vendor(s), ACFC Payment Integrity Dept. and/or or utilize payment integrity software to define, implement and maintain claim edits:;

• Coordinates with Payment Integrity Vendor; management staff in Claim Operations, Configuration or Operations Support Services to assure efficient application of medical claim payment policy edits and change management process
• Takes lead on implementation of claim edits for new business
• Executes test scripts to demonstrate edit accuracy, identifying and suggesting modifications to correct issues
• Researches and resolves issues preventing efficient implementation of new claim policy or policy customization/change, coordinating review and approval by Dept. or Medical Directors as required
• Utilizes resources to define best edit implementation source, identifying conflicts and communicating decisions and rational to affected associates
• Researches CMS Medicare Physician Fee Schedule, Medicare Claims Processing Manual, NCCI and/or OCE communications to define policy changes affecting Medicare Advantage business
• Facilitates intra-organizational forum to promote communication, education and synergy among medical coders functioning in various roles
• Mentors/trains Medial Policy Specialist.
  
  

Education/Experience

• Associate’s Degree preferred but not required
• Must have valid certified coding professional credential for both professional and outpatient medical coding from either AAPC or AHIMA
• 3-5 years Coding/Billing medical services to government and commercial carriers and/or; Claim Auditor, Medical Loss Review, Medical Payment Policy or Fraud and Abuse Auditor position with medical insurance carrier
• At least 2 years’ experience in a managed care organization setting in a provider reimbursement policy or provider network operations function
  
  

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.