Code Edit Professional 2

About the Role

Employment Type: Full time

Become a part of our caring community and help us put health first. The Code Edit Management Organization has a new Payment Integrity Professional 2 opening available. The Payment Integrity Professional 2 utilizes vendor platforms, claims processing platforms, and data to collaborate with key internal and external business stakeholders, while supporting claims code editing pre and post-implementation and functionality. The opportunity contributes to the overall goal of claims cost reduction and is available for WAH nationwide.

Where You Come In

• Foster relationships between Code Edit Management, internal stakeholders and multiple external code editing vendors
• Support of new code edit reviews, testing, implementation and maintenance management
• Management and resolution of code edit stakeholder inquiries
• Drive process improvements and ensure successful run of business

The Payment Integrity Professional 2 contributes to overall cost reduction, by increasing the accuracy of provider contract payments in our payer systems, and by ensuring correct claims payment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Use Your Skills to Make an Impact

Work Style

WORK STYLE: Remote, work at home. Minimal travel possible: Approximately 1-2x/year for trainings, meetings, conferences.

Work Hours

WORK HOURS: Monday-Friday, 8 hours/day, 5 days/week, in the employee's home time zone. Flexibility will be required to meet business needs.

Required Qualifications

• Proficient in managing diverse priorities, adept at swiftly transitioning between tasks based on urgency and demand
• Comfortable navigating and making decisions in a dynamic and everchanging environment
• Problem-solving abilities, including thinking outside the box and collaborating with others to achieve optimal outcomes
• Ability to work both independently and within a team structure, with minimal supervision
• Analytical Thinking
• Problem-solving abilities, including thinking outside the box and collaborating with others to achieve optimal outcomes
• Working knowledge of Microsoft Office Programs Word, SharePoint, and Excel
• Strong attention to detail
• Proficiency in verbal/written communication
• Ability to operate in a fast paced, agile, metric driven operational setting
• Commitment to upholding ethical standards and professional integrity in all interactions, including ability to maintain confidentiality
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• STRONGLY PREFERRED: Prior experience utilizing CASS
• STRONGLY PREFERRED: Prior experience utilizing code edit vendor tools such as: Rialtic Provider Inquiries Tool, ClaimsXten Web User Interface, Cotiviti What If Tool (WIT), Optum CES Tool, Cotiviti Claims Inquiry Tool (CIT), Nucleus or KnowledgeSource Tool.
• Prior experience working with external vendors and/or internal stakeholders
• Prior experience with Humana code edit claims processes
• Working knowledge of Microsoft Office Programs: PowerPoint and OneNote
• Prior experience in THOR Rule creation and/or processes
• Prior experience leading projects, and/or processes
• Prior experience in Claims Administration and Payment Integrity (CAPI) formerly Claims Cost Management (CCM)
• Prior experience analyzing medical claims data

Additional Information

Work at Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for