Provide clinical leadership and subject-matter expertise to support the analysis, configuration, and administration of complex medical policy content within claims processing systems.
Ensure the accurate implementation of medical policies, review criteria, and authorization requirements, while maintaining the integrity of system infrastructure and serving as a key liaison between business and technical teams.
Research and analyze system and business issues, develop high-level requirements, test and implement solutions, and audit and document outcomes.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, built on over 80 years of trust and motivated by member well-being, not profits. They are committed to providing best-in-class service, sustainability, and innovation.
Support medical policy functions by providing medical coding and system configuration.
Perform coding analysis and utilization reporting to recommend updates to medical policies.
Participate in cross-functional meetings to align with enterprise strategic priorities.
Wellmark is a mutual insurance company owned by policy holders across Iowa and South Dakota, built on over 80 years of trust. They are motivated by the well-being of their members and committed to sustainability and innovation.
Review and assign accurate ICD-10-CM, CPT, and HCPCS codes for medical diagnoses and procedures based on clinical documentation.
Ensure coding compliance with CMS guidelines, and state/federal regulations. Ability to write precise, professional, and well structured feedback to providers and team members.
Assist with claim reviews, denials, and coding-related audits to optimize revenue integrity.
Optima Medical is an Arizona-based medical group consisting of 30 locations and 130+ medical providers, who care for more than 200,000 patients statewide. Their mission is to improve the quality of life throughout Arizona by helping communities “Live Better, Live Longer” through personalized healthcare.
Review detailed claim reports from a variety of sources to predict current and future claim costs.
Research medical conditions and treatment options using available resources.
Document the medical review clearly, including an analysis of current clinical condition(s) and future annual claims projection.
Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With an entrepreneurial culture and a strong emphasis on analytics, they help employers better manage their risk.
Research and interpret payer policies in accordance with healthcare coding and regulatory requirements.
Identify common error areas that can be made into automated software logics that prevent overpayments.
Develop claims editing logics that promote payment accuracy and transparency across lines of business.
Rialtic is an enterprise software platform empowering health insurers and healthcare providers to run their most critical business functions. Founded in 2020 and backed by leading investors, they are tackling a $1 trillion problem to reduce costs, increase efficiency and improve quality of care.