Coding Specialist - Reimbursement Policy (Hybrid)

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day.

Primary Purpose

Parkland Community Health Plan's (PCHP's) Reimbursement Policy Coding Specialist will ensure accurate adjudication of claims by translating medical policies, reimbursement policies and clinical editing policies into effective and accurate reimbursement criteria.

Minimum Specifications

Education

• High school diploma or equivalent required.

Experience

• Three (3) years of coding experience in a health care or managed care setting is required.

Certification/Registration/Licensure

• Certified coding credentials (CPC, COC, CIC) required.

Skills or Special Abilities

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
• Knowledge of CPT/HCPCS, ICD-10-CM/PCS, and DRG coding guidelines and practices.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.
• Excellent analytical and problem-solving skills.
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to write clearly and succinctly with a high level of attention to detail.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs.
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Operations

• Analyzes details of benchmarking and creates resolution of the edits.
• Develops effective internal controls and monitor reports.
• Coordinates research efforts and responds to system inquiries and appeals.
• Performs CPT/HCPCS code, ICD-10 and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development.
• Reviews company-specific, CMS-specific, and competitor-specific medical policies, reimbursement policies and editing rules as well as conducts clinical research, data analysis and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
• Conducts research of claims systems and systems edits to identify adjudication issues and audit claims adjudication for accuracy.
• Supports Inpatient and Outpatient coding and reimbursement needs including APR DRG, EAPG, Fee-for-service and proprietary reimbursement.
• Supports the development of new reimbursement policies.

Quality

• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Regulatory

• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
• Promotes adherence to applicable state/federal laws, and the program requirements of accreditation agencies and federal, state, and private health plans.

Professional Accountability

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.