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MetroPlus Health PlanNew York City, NY
  • About NYC Health + Hospitals
  • MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • Develop and manage clinical benefit configuration process to ensure timely and accurate claims payment system configuration and claim processing.
  • Responsible for the codification and mapping of benefit product building, including the development and maintenance of the benefit configuration document and attaching appropriate service rules required for each benefit category.
  • Serve as subject matter expert in all areas of the medical plan configuration, medical utilization edits, service payment limits and service rules.
  • Develop workflows and business processes to ensure timely and accurate system build.
  • Act as a facilitator to accurately translate product benefit and all aspects of the service rules into a configurable document.
  • Provide business requirements to CORE configuration for purposes of translating clinical concepts into system configuration requirements.
  • Provide guidance to employees and providers regarding documentation concerns as they relate to coding and billing.
  • Develop workflows and business processes to ensure timely and accurate clinical claims payment system configuration (benefit configuration)
  • Translate clinical product benefits and all aspects of the service rules for system configuration
  • Provide business requirements to CORE configuration for benefit build
  • Support quality review and testing of all benefit setup prior to implementation and go-live
  • Partner with Product, IT Claims and Compliance departments to audit setups and configuration post go-live
  • Conduct testing and auditing on claims configuration updates and changes
  • Resolve escalated and complex processing, change requests, issues, or questions
  • Manage and maintain benefit documentation for internal & external customers
  • Annual review of new CPT & HCPCS code coverage determinations, considering member benefits, medical necessity and industry standard coverage policies
  • Responsible for own workflow assignments and must be able to take the initiative to resolve problems and meet deadlines
  • 3-5 years health plan benefit configuration experience
  • Certification as a professional coder (CPC) – preferred
  • 1+ years medical coding experience with demonstrated sustained coding quality
  • Advanced knowledge of CPT/HCPCS/Revenue Code, procedure coding, ICD10 coding, principles and practices
  • In-depth knowledge of coding/classification systems appropriate for inpatient, outpatient, HCC, CRG and DRG
  • Ability to research authoritative citations related to coding, compliance, and additional reporting needs
  • Demonstrates overall knowledge of claims processing for various insurances both private and government
  • Excellent computer skills, able to learn, use and toggle between multiple systems
  • Analytical skills and ability to create reports, charts and graphs (e.g., Microsoft Excel)
  • Ability to work independently or in a team setting, while handling multiple projects and adjusting to changes quickly while meeting all deadlines
  • Integrity and Trust

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