Coding and Cost Analyst I

Contributes to the organization’s strategic and financial goals by conducting thorough reviews of billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries, and detailed data reports. Makes reimbursement or recovery recommendations based on coding accuracy, billed statistics, policies, industry standards, and compliance with contractual, state, and federal regulations.

Job duties

• Supports other Health Plan departments by providing review and recommendation for correct coding, appropriate billing, and reimbursement.
• Completes clinical reviews related to claims, claim edits, appeals, and the grievance process.
• Assists with analysis of clinical risk related to underwriting, pharmacy, and finance departments.
• Recommends recovery efforts based on contracts, policies, procedures, and accepted industry standards.
• Reviews and validates pended and reconsidered claims when edits are applied by claim editing software from multiple vendors.
• Performs inpatient and outpatient high-dollar claim reviews following internal guidelines.
• Assists with reviews of quality concerns.
• Validates claim payments based on plan contracts and collaborates with the pharmacy team and PNM department.
• Creates and maintains reports to track department data.
• Assists in group discussions on challenging medical reviews.
• Helps onboard new team members as needed.
• Participates in workgroups and committees as requested.

Work is typically performed in a secure work-from-home office that follows HIPAA privacy standards. Occasional onsite department meetings may be required.