Clinical Coder

Job Description :

The Certified Clinical Coder - Program Specialist (PS V) reports to one of the Medical and

Dental Benefits Policy Managers in Medicaid.

The position performs advanced consultative and technical medical benefits work related to the development and implementation of Texas Medicaid medical benefits with a focus on clinical / medical billing and coding related projects and questions.

The position analyzes and researches medical billing and coding impacts to Medicaid’s medical benefits.

The Certified Clinical Coder (PS V) position identifies need for medical coding changes and

makes policy recommendations related to billing and coding, and researches state and federal regulations impacting Medicaid medical benefits.

This position requires excellent writing skills and strong research skills and will participate in medical benefit policy reviews.

This position is expected to understand state and federal Medicaid and CHIP laws and regulations, have knowledge of complex national coding requirements, CMS requirements, and strong knowledge of Medicare and Medicaid billing processes, as well as an awareness of the difference between Medicaid insurance and private payer health insurance.

This position is expected to have experience and strong knowledge of CPT, HCPCS, NCCI and ICD.

This position works under the general direction of the Manager with a high degree of latitude for the use of initiative and independent judgment.

The Certified Clinical Coder Program Specialist V in this position must be proactive in seeking input from other staff in the Medicaid and CHIP Services Department and demonstrate the ability to work as an effective team member within Medical Benefits as well as other divisions and business areas within HHSC. Essential Job Functions :

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Keeps the Medical Benefits Manager informed of pertinent Medicaid medical benefit issues and coding impacts as required or as necessary.

30%) Researches, analyzes, and synthesizes Medicaid medical benefit policy, complicated federal and state regulations, client information, and claims processing information for medical benefit reviews with a focus on clinical / medical coding and billing related projects.

Analyzes, researches and tracks quarterly and annual ICD, CPT, HCPCS, and NCCI changes. Conducts research on managed care organization (MCO) benefit coverage, private payer benefit coverage, CMS, and other state Medicaid benefit coverage during the policy development process.

Keeps team apprised of billing and coding updates and related information.

25%) Participates and may lead in the development, planning, and implementation of new or revising current medical benefit policies.

Researches, analyzes, and synthesizes very technical information such as standards of care, evidence-based practices, and peer reviewed literature using a variety of resources and websites and applies findings to medical and dental benefit policies.

Collaborates, as needed, with Medical Benefits staff as well as HHSC staff in other programs and other State agencies and the claims system administrators for program benefit policy development, planning, and implementation.

Participates in medical policy meetings and participates in policy discussion by providing comments and recommendations orally or in writing.

Performs quality review of policy language and claims processing system to ensure all changes are appropriate and have been captured accurately.

20%) Provides training, technical assistance, and guidance to staff on clinical coding and billing. Responds in timely manner to internal / external communications and requests for current coding related policy information.

Prepares policy updates, summaries, reports, or other documents and keeps management informed of pertinent issues. Works with internal and external stakeholders to identify the need for policy changes through the analysis of claims appeals and denials, provider complaints, billing and coding questions, and prior authorization requests.

15%) Participates and may lead in public meetings or workgroups engaged in research, analysis, and evaluation of medical benefit issues or initiatives.

Acts as the liaison with HHSC staff and other business areas and HHS agencies by providing complex technical assistance and guidance on medical benefit coding and billing related changes during workgroups and meetings.

Collaborates with HHSC staff and other HHS agencies to ensure that medical benefits information in the Texas Medicaid Provider Procedures Manual (TMPPM) and other Medicaid materials is accurate and in accordance with policies and procedures.

Participates in Post Implementation Utilization Report (PIUR) meetings for medical and dental policies in order to identify if additional benefit changes are necessary and provides guidance and advice on how to implement these changes.

10%) Assists in developing complex memos, briefs, and other documents for HHSC Executive Leadership regarding medical benefit changes.

Develops and provides recommendations for benefit coverage to HHSC Executive Leadership. Supports team members in the development of medical benefit policy.

Other duties, as assigned, include but are not limited to actively participating in or serving in a supporting role to meet the agency’s obligations.

Knowledge Skills Abilities :

Knowledge of health and human services agencies and programs, and state and federal Medicaid and CHIP laws and regulations.

Knowledge of HCPCS, CPT, NCCI and ICD coding information and knowledge of federal and state billing compliance standards.

Strong skills in analyzing and evaluating complex federal and state legislation. Skill in researching, analyzing, and synthesizing medical policy, claims processing systems, and program issues.

Strong skill in developing and evaluating policies and procedures, assessing risks, and making billing and coding policy recommendations.

Strong skills in written and oral communication, including the ability to make public presentations, and write technical information in an understandable format.

Skill in project planning, evaluation, and implementation. Highly organized and the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.

Ability to effectively communicate, facilitate meetings and maintain working relationships with staff or program stakeholders.

Ability to exercise creative problem-solving techniques in a highly complex environment. Ability to work cooperatively as a team member in a fast-paced, deadline-orientated environment.

Ability to work independently and perform work with a high degree of attention to detail.

Proficient in the use of Microsoft Office products is required.