PrePay Coding Analyst

Florida Blue   •  

Jacksonville, FL

Industry: Information Services


5 - 7 years

Posted 330 days ago

This job is no longer available.

Essential Job Functions:

- Independently perform analysis of high risk and/or high dollar claims on a pre-payment basis utilizing coding and medical records analysis to ensure claims are neither over nor underpaid

- Perform medical chart audits to assure that codes billed are appropriate and supported by documentation in the patient’s record with the appropriate CPT, HCPC or ICD-10 code

- Leverage facility coding background to assess high risk claims for inappropriate application of associated Florida Blue policies, industry standard billing and care practices that may impact claims payment (e.g. MCG, LCD, Authorizations, Covered Benefits and Appropriateness of Service Setting).

- Request and independently review pertinent medical documentation to validate/invalidate potential issues identified on high risk/complex claims

- Determine claim level financial impact based on unique member benefits and provider contract terms, rates and payment


- Ensure claims processing compliance with overarching administrative regulations (Federal, State of Florida, BCBS Association, etc.)

- Perform claims level analysis of appropriate provider coding and billing practices and/or guidelines

- Coordinate and communicate directly with provider personnel as necessary to understand and communicate identified coding/billing discrepancies

- Thoroughly document identified issues to support claim adjustments(including supporting medical documentation or coding rationale)

- Participating in special projects, as needed, to support change in the supporting process or policies that will impact the pre-payment claims or care processes

- Identify and document upstream process gaps driving incorrect payment for remediation and prevention

Minimum Job Requirements:

- Bachelor's degree or equivalent work experience

- Current coding certifications with American Association of Professional Coders (AAPC or American Health Information Management Association (AHIMA) (CPC, CCS, etc.)

- 5+ years related work experience or equivalent combination of transferrable experience and education, including:

- Experience with and knowledge of multiple provider reimbursement and pricing methodologies (DRG, SPC, OFS, POC, Global Pricing, Per Diem, etc.)

- Demonstrate proficient working knowledge of at least five of the following: medical terminology, claim audit procedures,

provider contract understanding, claims processing procedures and guidelines, provider authorizations, provider billing (Institutional claims), medical coding of institutional services, concurrent review.

- Proficiency/experience working with some of the following Tools/Apps:

- Diamond


- Contract Management System


- AHA coding clinic

- Network Suite of Tools