Medical Coding Appeals Analyst at Elevance Health

Indianapolis, Indiana, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

NoVisa

HealthcareIndustries

Requirements

BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience which would provide an equivalent background
Certified Professional Coder (CPC) or Registered Health Information Administrator (RHIA) certification required

Responsibilities

Ensures accurate adjudication of claims by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria
Reviews medical record documentation in support of Evaluation and Management, CPT, HCPCS, and ICD-10 codes
Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducting clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy
Translates medical policies into reimbursement rules
Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits
Coordinates research and responds to system inquiries and appeals
Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy
Performs pre-adjudication claims reviews to ensure proper coding was used
Prepares correspondence to providers regarding coding and fee schedule updates
Trains customer service staff on system issues
Works with providers contracting staff when new/modified reimbursement contracts are needed

Skills

Medical Coding

CPT

HCPCS

ICD-10

Claims Adjudication

Reimbursement Policies

Clinical Research

Data Analysis

Medical Policy Review

Fee Schedule Updates

Evaluation and Management Coding

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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