Medicare Specialist
Medicare Specialist
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Job Description
The Medicare Specialist researches maintains updates and creates new methodologies for Medicare payment systems to implement in Prime Health Services (PHS) suite of products as appropriate and understands NCCI/MUE billing edits as related to Prime products.
Essential Job Functions
- Researches and deciphers complex legal and regulatory sources regarding payment rules for Medicare payment systems
- Collaborates with Regulatory Compliance colleagues on how Medicare rules apply to Personal Injury Protection and Workers Compensation reimbursement
- Drafts concise documentation for payment proceduresincluding payment calculation logicand interacting with the development team to refine that documentation into user stories and project plans
- Creates and updates internal documentation and processes as needed for all Medicare based products
- Identifies issues upfront and communicate clearly to team members and leadership
- Manages competing priorities and delivers quality information and analysis while adhering to deadlines
- Develops manages and maintains rules in the PHS proprietary bill review software for all Medicare payment policies and systems
- Reports any showstopper issues to the Supervisor of Compliance
- Performs unit and acceptance testing as necessary
- Performs other duties as assigned
- Bachelors Degree in health care administration business and/or other related discipline (Related experience in a health care administration setting may be substituted for educational requirements)
- Outpatient Coding Credential (Certified Professional Coding (CPC) Certified Outpatient Coder (COC) or Certified Coding Specialist- Professional (CCS-P) are preferred
- Proficient computer skills - expert knowledge of Microsoft Office Suite (Excel Word PowerPoint) is required
- 2 years of relevant work experience (physician practice hospital ancillary provider health insurance company or integrated delivery system) is preferred; the Medicare Specialist Senior must possess 5 years of direct experience
- Knowledge of ICD-10CM CPT4 Revenue Codes DRGs base rates HCPCS coding Medicare regulations payment policies OPPS and related governmental guidelines and provider reimbursement methodologies are required
Competencies
- Excellent planning communication(oral and written) documentation and organizational abilities
- Advanced mathematical analytical and problem-solving skills
- Ability to interpret and summarize results of various analyses in a timely and meaningful way
- Ability to work cooperatively with multidisciplinary teams and/or independently
Benefits
- Medical Insurance (high deductible plan with an HSA)
- Dental Insurance
- Vision Insurance
- Short-term and long-term disability paid by the company
- Group term life paid by the company
- PTO - 160 hours (4 weeks) with the ability to roll over 40 hours and cash out 40 hours at the end of the year
- Fitbit program with monetary rewards
- Employee recognition programs with monetary rewards
- Corporate office amenities - specialty coffee machines assorted tea options smoothie bar collaborative workspaces fruit provide by company and an onsite market
- Regular employee events such as potlucks video game tournaments door decorating contests Mental Health Awareness Month activities and a company carnival just to name a few of our past events
About Us
Prime Health Services (PHS) is a national medical cost containment company with a noteworthy PPO Network used by insurance carriers TPAs self-insureds and governmental entities. Our tech-focused nature allows clients to take advantage of the flexibility of customization while not compromising on bill processing speed. Since 2001 we have specialized in medical provider network development and offer clients a tailored approach to medical cost containment: quality health care at discounted rates.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
