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Coding Analyst Job in New York, New York

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Job Title: Coding Analyst

Employer:1199 SEIU Benefit Funds
Skills:Medical terminology/coding,claims auditing,analytical skills,advanced Excel
Specialties:Reviewing outpatient Claims with CPT/HCPCS Codes and Modifiers
Required Certifications:CPC
Required Experience:5 to 7 years
Location:330 W 42nd Street New York 10036, NY, US
Date Posted:6/4/2019


Coding Analyst

 Clinical Compliance Department

1199SEIU Benefit Funds (Non – Profit Health Plan)

New York, NY



Under direct management by Director of Clinical Compliance, this position is responsible for developing CPT/HCPCS code reimbursement policies and reimbursement rates for outpatient services. The organization will be migrating from an existing code editing system to a new robust software in which the implementation will be 9 – 12 months and Clinical Compliance is one of the leading departments for this transition. This is not a remote position.


  • Develop quarterly and annually CPT and HCPCS code reimbursement policies and reimbursement rates for outpatient services
  • Perform comprehensive maintenance review on all HCPCS codes in which the 12 categories of codes will be examined which requires modernization of coding reimbursement policies inclusive of coding regulations and coding configuration
  • Collaborate with internal and external stakeholders with the transition and implementation of migrating to a prospective claim editing software. This will convert to maintenance work to continue to add new customized coding rules, logic and/or CHC programs with the outcome of effective operational solutions for compliance with coverage, payment and coding regulations.
  • Develop enhanced prospective claims auditing / customized clinical coding reimbursement policies and coding configuration outpatient covered services utilizing CHC/McKesson’s Policy Administration Module (PAM).  Monitor measure and manage PAM criteria with annual review or more with reporting outcome results. Develop documents as necessary
  • Provide coding support for CHC/McKesson claims auditing software applications (ClaimCheck, CCI, PAM, etc.) utilize vendor web­ based programs to support these applications
  • Perform complex Compliance Claims Audits or clinical reviews on pended claims to investigate, research, and analyze CPT and HCPCS claims data.  When indicated, identify errors, wasteful/excessive billing practices on a claim, provider and/or code levels. This includes trouble shooting, resolving the issue(s) and/or recommending corrective action for deficiencies, irregularities and anomalies. Requires interpretation of industry standard health care coding conventions and Fund policies
  • Utilize Statistical Analysis Software (SAS) to examine large claims data sets to trend existing provider billing patterns as compared to industry standard coding regulations with recommendations of industry standard coding logic, business rules and configuration
  • Collaborate with different departments to define the PAM criteria according to current and standard clinical coding rules/logic. Interact with QNXT production dept. to perform pre and post testing
  • Work closely with management to develop manage and update operating procedures or other relevant documentation for program specific data management activities; monitor operational activities to ensure compliance with documented policies, procedures standards and quality improvement processes.  Generate timely reports, analyze and summarize Return on Investment (ROI) results, track and trend outcomes + recommend custom solutions for all clinical compliance initiatives. Craft user manuals, policy/procedures, or other pertinent documentation to support clinical compliance initiatives. Train staff as necessary.
  • Design and conduct quality control and improvement activities (utility of software applications, report generation, test scenario development, check report results for quality, claims auditing, etc.), track and trends results, and recommend corrective action for problems, irregularities and anomalies
  • Collaborate, coordinate and act as an Operational Liaison with vendor, business users and Information Technology resource staff to support ongoing departmental initiatives and quality improvement efforts
  • Perform additional duties and projects as assigned by management
  • Must meet performance standards including attendance and punctuality


  • Bachelor’s degree in health care or related field or equivalent years of work experience required
  • Minimum five (5) years senior level, progressive experience in medical or hospital outpatient claims adjudication, clinical coding reviews for claims settlement, claims auditing, utilization review AND/OR working in a provider setting assigning CPT and/or HCPCS codes for outpatient services
  • Advanced skill level in Microsoft Word and Excel required
  • AAPC certification in professional medical coding required
  • Intermediate level experience with Change Healthcare/McKesson claims auditing software programs
  • Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare’s claims’ processing policies, coding principals and payment methodologies
  • Familiarity with SAS to examine large data sets to trend provider billing patterns as compared to industry standard coding conventions
  • Strong math aptitude with frequent use of calculator functions, critical thinking and analytical/organizational skills
  • Effective written and interpersonal communication skills
  • Effective time management and project management skills; Detailed oriented while demonstrating accountability, teamwork+ initiative and must have capability of working in fast paced, high volume department
  • Strong critical thinking, and analytical/organizational skills and ability to work well with competing priorities and meet strict timelines; must have proven track record of quality, process improvement and contributing to efficient operations.
  • Demonstrated experience in managing and prioritizing multiple projects simultaneously while adapting to rapidly changing schedules and workflows
  • Excellent verbal and written communication skills a must
  • Able to work well in fast paced environment with competing priorities and strict timelines

To Apply:

Email resume directly to Director, Elizabeth Zappa - Elizabeth.Zappa@1199funds.org


Email resume directly to Director - Elizabeth Zappa - Elizabeth.Zappa@1199funds.org

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