Medicare Specialist at Prime Health Services, Inc.

Franklin, Tennessee, United States -

Full Time

Start Date

Immediate

Expiry Date

18 Dec, 25

Salary

0.0

Posted On

19 Sep, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medicare Payment Systems, Regulatory Compliance, Documentation, Payment Procedures, Coding, ICD-10CM, CPT4, Revenue Codes, DRGs, HCPCS Coding, Analytical Skills, Problem-Solving, Communication, Organizational Skills, Team Collaboration, Microsoft Office Suite

Industry

Insurance

Description

Description The Medicare Specialist researches, maintains, updates and creates new methodologies for Medicare payment systems to implement in Prime Health Services’ (PHS) suite of products as appropriate and understands NCCI/MUE billing edits as related to Prime products. Essential Job Functions Researches and deciphers complex legal and regulatory sources regarding payment rules for Medicare payment systems Collaborates with Regulatory Compliance colleagues on how Medicare rules apply to Personal Injury Protection and Workers Compensation reimbursement Drafts concise documentation for payment procedures—including payment calculation logic—and interacting with the development team to refine that documentation into user stories and project plans Creates and updates internal documentation and processes, as needed for all Medicare based products Identifies issues upfront and communicate clearly to team members and leadership Manages competing priorities and delivers quality information and analysis while adhering to deadlines Develops, manages, and maintains rules in the PHS proprietary bill review software for all Medicare payment policies and systems Reports any showstopper issues to the Supervisor of Compliance Performs unit and acceptance testing as necessary Performs other duties as assigned Requirements Bachelor's Degree in health care administration, business and/or other related discipline (Related experience in a health care administration setting may be substituted for educational requirements) Outpatient Coding Credential (Certified Professional Coding (CPC), Certified Outpatient Coder (COC), or Certified Coding Specialist- Professional (CCS-P) are preferred Proficient computer skills - expert knowledge of Microsoft Office Suite (Excel, Word, PowerPoint) is required 2+ years of relevant work experience (physician practice, hospital, ancillary provider, health insurance company or integrated delivery system) is preferred; the Medicare Specialist – Senior must possess 5 + years of direct experience Knowledge of ICD-10CM, CPT4, Revenue Codes, DRGs, base rates, HCPCS coding, Medicare regulations, payment policies, OPPS, and related governmental guidelines and provider reimbursement methodologies are required Competencies Excellent planning, communication(oral and written), documentation, and organizational abilities Advanced mathematical, analytical, and problem-solving skills Ability to interpret and summarize results of various analyses in a timely and meaningful way Ability to work cooperatively with multidisciplinary teams and/or independently Benefits Medical Insurance (high deductible plan with an HSA) Dental Insurance Vision Insurance Short-term and long-term disability paid by the company Group term life paid by the company PTO - 160 hours (4 weeks) with the ability to roll over 40 hours and cash out 40 hours at the end of the year Fitbit program with monetary rewards Employee recognition programs with monetary rewards Corporate office amenities - specialty coffee machines, assorted tea options, smoothie bar, collaborative workspaces, fruit provide by company and an onsite market Regular employee events such as potlucks, video game tournaments, door decorating contests, Mental Health Awareness Month activities, and a company carnival just to name a few of our past events About Us Prime Health Services (PHS) is a national medical cost containment company with a noteworthy PPO Network used by insurance carriers, TPA’s, self-insureds, and governmental entities. Our tech-focused nature allows clients to take advantage of the flexibility of customization while not compromising on bill processing speed. Since 2001, we have specialized in medical provider network development and offer clients a tailored approach to medical cost containment: quality health care at discounted rates.

Responsibilities

The Medicare Specialist researches and updates methodologies for Medicare payment systems and collaborates with compliance colleagues on reimbursement rules. They draft documentation for payment procedures and manage rules in proprietary software for Medicare policies.