Job Description

Policy Coding and Enforcement Analyst

The Policy Coding and Enforcement Analyst will work closely with Medical Policy and Configuration Management to ensure proper coding and translation of medical policies into enforcement rules to implement within the automated claims editor.

This position is eligible for remote work, but quarterly travel will be required to the corporate office located in Tampa, Florida.

Policy Coding and Enforcement Analyst - Essential Functions and Responsibilities:

• Review each Medical Policy to identify necessary coding and enforcement updates

• Apply proper ICD-10, CPT, and HCPCS coding to Medical Policies

• Develop Medical Policy enforcement rules, including rationale for interpretation, supporting evidence, and documentation, from Medical and Payment Policies

• Identify and record coding and enforcement changes for each policy

• Perform coding and enforcement analysis and research as needed

Policy Coding and Enforcement Analyst Minimum Qualifications:

• Bachelors degree in biology, chemistry, medicine, nursing, medical technology, or related field or equivalent related work experience

• Minimum 5 years work experience

• Coding certification: RHIT, CPC, CCS or similar

• Clinical experience with a background of ICD-10, CPT, and HCPCS coding principles

• Experience with developing claim editing and enforcement rules

• High attention to detail, including proper documentation

• Strong understanding of laboratory billing and reimbursement practices

• Strong verbal and written communication skills with the ability to simply convey complex subject matter

• Independent, capable of decision making with limited information

Policy Coding and Enforcement Analyst Preferred Qualifications:

• Certified Medical Coder - RHIT, CPC, CCS or similar

• Configuration experience edit building or testing

• Knowledge of and experience with laboratory medical coding rules and regulations, compliance, and reimbursement

• Experience with Centers for Medicare & Medicaid Services (CMS) and industry standard billing, compliance, and reimbursement methodologies

• Familiarity with commercial payor medical policies

• Familiarity with government programs, such as Medicare and Medicaid

• Experience with data analysis tools

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