The Medical Claims Research (MCR) Coordinator II is responsible for oversight of the MCR daily functions. As the preceptor/mentor they will review, develop, and provide on-going training and educational tools to staff. Assists with prioritizing activities of the MCR staff to meet the operational needs and goals of the department and ensure accurate and timely completion of all claim edit, high dollar claim review, hospice, Individual PPO claim review and out of network negotiation related inquiries. This position is also responsible for a MCR Coordinator workload; contributing to the achievement of the strategic and financial goals of the Health Plan by conducting thorough reviews of billed services, authorizations, plan benefit documents, itemized statements, medical records, discharge summaries and detailed data reports. Is utilized to make reimbursement or recovery recommendations based on appropriate coding, billed statistics, Health Plan policies, industry standards and compliance with contractual, state and federal regulations.
Reports to the Director, Medical Policy and Appeals.
Competencies and Skills:
Demonstrates effective analytical skills and the ability to summarize findings and suggest an action plan.
Demonstrates exceptional ability to work independently and as a team.
Demonstrates exceptional ability to research operational, clinical, coding, and industry references.
Demonstrates self motivation and ability to effectively manage, prioritize and complete multiple projects in a timely fashion.
Demonstrates exceptional computer skills including Microsoft Office and Mainframe applications.
Demonstrates excellent knowledge of managed care principles, auditing, billing, reimbursement and coding procedures.
Demonstrates excellent verbal and oral communication skills to effectively and professionally interact with varying levels of personnel.
Maintains ongoing continuing education requirements to satisfy the CPC certification including but not limited to of CPT, HCPCS and ICD-9/10 coding principals, government regulations regarding coding, industry standards and claim edit software database information.
Education and or Experience:
Current RN or LPN Pennsylvania licensure required. Minimum three to five years clinical experience in an acute inpatient setting or relevant physician reimbursement required. Minimum of three years experience as a MCR I required.
CPC certification required.
Working Conditions/Physical Demands:
Work is typically performed in an office environment.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
ABOUT GEISINGER: Geisinger is a physician-led health system comprised of approximately 30,000 employees, including nearly 1,600 employed physicians, 13 hospital campuses, two research centers, and a 583,000-member health plan Geisinger is nationally recognized for innovative practices and quality care. Geisinger serves more than 3 million people in central, south-central and northeast Pennsylvania and also in southern New Jersey with the addition of National Malcolm Baldridge Award recipient AtlantiCare, A member of Geisinger. In 2017, the Geisinger Commonwealth School of Medicine became the newest member of the Geisinger Family.
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. For more information, visit www.geisinger.org, or connect with us on Facebook, Instagram, LinkedIn and Twitter.
** Does not qualify for J-1 waiver. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
*Domestic partner benefits not applicable at Geisinger Holy Spirit.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.