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The primary function of the Senior Administrative Claims Specialist (CPC) is to serve as the resource for medical coding reviews within our Medical Claims Operation.  Provide in-depth research on new or unusual procedures and make recommendations as appropriate.  Provide support to the Medical Claims and Legal Departments. 
 
RESPONSIBILITIES

• Review medical documentation to verify correct CPT code usage by provider/facility
• Remain current regarding NY Fee Schedule, Medicare, and coding literature
• Research for documentation to support payment reimbursement
• Create letters of explanation and/or affidavits when coding updates have been performed
• Prepare support for Counsel and Litigation Department to use for defending arbitration and trials; attend hearings to testify as necessary
• Serve as a resource within the Department related to billing and coding issues
• Other duties as assigned

 
QUALIFICATIONS

• Certified Medical Coder (CPC, CCA, CCS) with high degree of competence in this area with 3-5 years of NYFS/Workers Compensation coding experience
• Hospital and Surgical Coding experience preferred but not necessary
• High School Diploma or GED equivalent; College degree preferred

Knowledge of CPT coding guidelines, medical terminology, anatomy, and physiology

Knowledge of CMS/Medicare, NCCI, AMA

NJ PIP and/or Workers Compensation experience preferred but not necessary

Knowledge of legal, regulatory, and policy compliance issues related to medical coding and documentation

Analytical and problem-solving capability

Demonstrate effective verbal and written communication skills

Proficient with the use of Microsoft Office products (Word, Excel, Outlook) 

Strong internet research skills

Ability to establish and maintain positive and effective work relationships with coworkers, medical providers, and customers

Ability to participate in a teamwork approach to accomplish tasks