Shire Jobs

We offer remote work opportunities (AK, AR, AZ, CA, *CO, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI and WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Conducts retrospective medical claim reviews and claims adjudication for coding determinations. Provides coding-related information to medical directors, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed. Functions as the designated recipient for factual network provider claim review requests. Develops determination letters. Provides support to non-clinical and clinical staff on coding and retrospective medical claims review processes.

Education and Experience

Required:

Current Certification as a Professional Coder (CPC) or Certified Professional Coder Hospital (through the American Academy of Professional Coders) If supporting TRICARE contract, must be a U.S. Citizen If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation 2+ years of clinical coding experience 2+ years of claims processing experience Preferred:

Experience in the private medical industry, health insurance or Managed Care field Experience in a fast-paced corporate environment Familiarity with TRICARE and the military healthcare delivery system

Key Responsibilities

Performs claims coding reviews using current coding guidelines. Performs focused claims reviews as requested by management and summarizes findings. Identifies and reports potential fraudulent or quality issues. Acts as a resource for TriWest staff on ICD-10-CM, HCPCS and CPT coding. Researches TRICARE manuals for benefits, limitations and exclusions and current coding guidelines. Monitors and tracks timeliness of retrospective claims reviews response to ensure compliance with required timelines for completion of assigned reviews. Identifies questionable review decisions and forwards to the appropriate Medical Director for evaluation and/or corrective action. Provides accurate data entry in the medical management and claims system. Performs other duties as assigned. Regular and reliable attendance is required.

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required. Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Problem Solving / Analysis: Ability to solve problems through systematic analysis of rocesses with sound judgment; has a realistic understanding of relevant issues. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Knowledge of ICD-10, HCPCS and CPT coding; ability to maintain the confidentiality and security requirements of medical records; ability to meet department performance standards.

Working Conditions

Working Conditions:

Availability to work any shift Works within a standard office environment, with minimal travel Extensive computer work with prolonged sitting

Annual base salary for Colorado, Hawaii and Washington State residents: $69,000 - $89,000 depending on experience