Claim Edit and Vendor Integrity Specialist, Geisinger Health Plan ( Eastern United States resident )
Core
Lead the development, testing, and maintenance of prospective claim edits and vendor partnerships to ensure payment compliance and coding accuracy in a healthcare claims environment.
Role type
Senior IC claims integrity specialist (vendor management & edit development)
Builds
Prospective claim edits, ClaimsXten Policy Management Module, vendor implementation support
Domain
Health Insurance / Managed Care / Claims Processing
Required skills
CPT, ICD-10, HCPCS coding expertise, claim edit validation, vendor relationship management, issue escalation and resolution, performance monitoring, system testing, policy development, mentoring
Preferred skills
Health Insurance/Managed Care experience, Specialty Training Program graduation
Technologies
ClaimsXten, national correct coding standards
Responsibilities
Lead the Edit Expansion Committee and routine maintenance meetings with vendor partners; Test and verify new claim edits during implementation; Research CPT codes to clarify coding issues; Determine payment compliance with clinical and reimbursement policies; Coordinate yearly opportunity analysis and performance reporting; Mentor less experienced staff and new hires.
Seniority
Senior, hands-on IC with leadership responsibilities