**Duties & Responsibilities** : + Conducts routine assessments of current claims edits and ensures comprehensive and defensible editing across all Healthfirst product lines. + Proactively identifies areas of opportunity with respect to new edits and modifications to existing edits. + Leads implementation efforts with respect to new or modified edits and works with other departments to ensure proper integration with existing systems and edits. + Monitors and reports on performance of current claims editing packages + Supports claims editing escalated provider disputes/appeals and provides guidance across all areas of the company with regards to claims editing and proper coding, billing, and payment. + Researches and provides feedback on claims editing performance issues, both internally and externally with providers, vendors, etc. + Works closely with claims editing vendors on maintaining and updating edits as changes in the regulatory, legislative, or industry accepted payment policy requires. + Collaborates with other departments to improve compliance with coding conventions and clinical practice guidelines + Supports continuous improvement and quality initiatives to improve processes across departments. + Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider. + Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards. + Navigates CMS and State specific websites, as well as AMA guidelines, and compare to current payment policy configuration in order to resolve the providers payment discrepancy. + Reviews medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines in order to decide if a claim adjustment is necessary. + Processes claim adjustment requests following all established adjustment and claim processing guidelines. + Identifies and escalates root cause issues to supervisor for escalated review. + Reviews and responds to internal escalated provider disputes transferred by management and other associates. + Acts as liaison with other departments when additional clarification is needed about claims payment policy disputes. + Additional duties as assigned **Minimum Qualifications:** + Coding certification from either American Academy of Professional Coders (AAPC), Certified ProfessionalCoders (CPC) or American Health Information Management Association (AHIMA). + High school diploma or GED from an accredited institution. **Preferred Qualifications:** + Previous relevant experience + Bachelors degree in related field + Time management, critical/creative thinking, communication, and problem-solving skills + Demonstrated professional writing, electronic documentation, and assessment skills. + Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills. + Knowledge of anatomy and pathophysiology medical terminologies. Compliance & Regulatory Responsibilities: See Above License Certifications: See Above WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.