[Remote] Medicare/Medicaid Claims Editing Specialist

Note: The job is a remote job and is open to candidates in USA. Commonwealth Care Alliance is a healthcare organization focused on improving the lives of its members through personalized care. The Medicare/Medicaid Claims Editing Specialist will be responsible for developing claims auditing and clinical coding edits to ensure compliance with Medicare and Massachusetts Medicaid regulations, while also analyzing claims data and collaborating with internal stakeholders on cost-saving initiatives.

Responsibilities

• Develop enhanced, customized prospective claims auditing and clinical coding and reimbursement policies and necessary coding configuration requirements for Optum CES and Zelis edits
• Quarterly and Annual review and research, as necessary on all new CPT and HCPCS codes for coding logic, related Medicare/Medicaid policies to make recommend reimbursement determinations
• Analyze, measure, manage, and report outcome results on edits implemented
• Utilize data to examine large claims data sets to provide analysis and reports on existing provider billing patterns as compared to industry standard coding regulations, and make recommendations based on new/revised coding edits for presentation to Payment Integrity committee meetings
• Analyze, measure, manage, and report outcome results on edits implemented
• Use and maintain the rules and policies specific to CES and Zelis
• Query and analyze claims to address any negative editing impacts and create new opportunities for savings based on provider billing trends
• Liaison between business partners and vendors; bringing and interpreting business requests, providing solutioning options and documentation, developing new policies based on State and Federal requirements, host meetings, and managing projects to completion
• Define business requests received, narrow the scope of the request based on business needs and requirements, provider resolution option based on financial ability and forecasting for small to large Operations Management
• Collaborate system and data configuration into CES (Claims Editing System) with BPaaS vendor and other PI partners, perform user acceptance testing, and analyze post production reports for issues
• Support collaboration between PI/Claims and other internal stakeholders related to the identification and implementation of cost-savings initiatives specific to edits

Skills

• Bachelor's Degree or Equivalent experience
• 7+ years of Healthcare experience, specific to Medicare and Medicaid
• 7+ years progressive experience in medical claims adjudication, clinical coding reviews for claims, settlement, claims auditing and/or utilization review required
• 7+ years experience with Optum Claims Editing System (CES), Zelis, Lyric or other editing tools
• Extensive knowledge and experience in Healthcare Revenue Integrity, Payment Integrity, and Analytics
• 5+ years of Facets Claims Processing System
• Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)
• Medical Coding, Compliance, Payment Integrity and Analytics
• Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e . Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.)
• Advanced experience of medical terminology and medical coding (CPT, HCPCS, Modifiers) along with the application of Medicare/Massachusetts Medicaid claims' processing policies, coding principals and payment methodologies
• Ability to work cross functionally to set priorities, build partnerships, meet internal customer needs, and obtain support for department initiatives
• Ability to plan, organize, and manage own work; set priorities and measure performance against established benchmarks
• Ability to communicate and work effectively at multiple levels within the company
• Customer service orientation; positive outlook, self-motivated and able to motivate others
• Strong work ethic; able to solve problems and overcome challenges
• English
• Certified Professional Coder (CPC)
• Certified Inpatient Coder (CIC)
• Certified Professional Medical Auditor (CPMA)
• Masters Degree

Benefits

• You may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Company Overview

• Commonwealth Care Alliance is an integrated care system that advocates for economical healthcare policies. It was founded in 2003, and is headquartered in Boston, Massachusetts, USA, with a workforce of 1001-5000 employees. Its website is http://www.commonwealthcarealliance.org.

Company H1B Sponsorship

• Commonwealth Care Alliance has a track record of offering H1B sponsorships, with 10 in 2025, 16 in 2024, 11 in 2023, 18 in 2022, 21 in 2021, 15 in 2020. Please note that this does not guarantee sponsorship for this specific role.