Coding Specialist - Benefit and Contract

Date: Jan 11, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 6489 


Position Summary/Position


The Benefit and Contract Coding Specialist performs on-going review of all applicable state and federal regulations, as well as internal contracts for alignment with claim adjudication related system configuration. This position is responsible for analyzing and codifying new contracts, Divisions of Financial Responsibilities (DOFRs), and Medi-Cal and Medicare benefits in compliance with AMA and regulatory guidelines. The incumbent may also assist in reviewing and resolving DHCS and CMS encounter rejection data as it related to coding and billing. The Benefit and Contract Coding Specialist reviews information related to claims reconciliation and assists in IEHP’s efforts to maximize Provider reimbursement and clean-claim standards. The Specialist is also responsible for assisting the Provider Services Department in identifying opportunities for improvement in provider billing practices. 

Major Functions (Duties and Responsibilities)


1. Performs ongoing claims adjudication review and coding assistance to the team by reviewing all Provider contract compensation amendments and agreements.
2. Conducts research for coding regulations and requirements related to Medi-Cal and Medicare benefits. 
3. Analyzes IEHP claims and encounter data to identify incomplete or inaccurate configuration and/or incorrectly billed claims. 
4. Works closely with the Claims System Configuration Team, Contracting department, and Claims department to provide coding support related to contracts and benefits. 
5. Develops and maintains tracking log for Medi-Cal Local Codes and other coding crosswalks. 
6. Assist with all regulatory, internal, external or vendor audits as required. 
7. Notifies Claims System Configuration team of new codes and regulations.
8. Assist in the implementation and maintenance of coding rules to be administered in either McKesson or Meditrac.
9. Codify DOFRs, contracts, and benefits. 
10. Demonstrate a commitment to incorporate LEAN principles into daily work.

Experience Qualifications


Three (3) years of medical coding experience required.

Preferred Experience


Managed Care Coding experience preferred. Contract coding experience preferred. Encounter or HCC coding experience preferred.

Education Qualifications


High School Diploma or GED required.

Professional Certification


AHIMA or AAPC Coding Certification required.

CCS-P or CPC-P preferred.  

Knowledge Requirement


Knowledge of coding for both Medi-Cal and Medicare services. Knowledge of coding processes, guidelines and working knowledge of Centers for Medicare & Medicaid Services (CMS) as well as Department of Health Care Services (DHCS). Knowledge of CPT, HCPCS, and ICD-10 guidelines are required. 
Knowledge in clinical processes and methodology concepts as they relate to all lines of business and Part D plans is preferred. Knowledge of claims processing and/or basic system configuration processes preferred. Knowledge of Medi-Cal local codes preferred.

Skills Requirement


Excellent written, oral and presentation skills, proficiency in Microsoft Word, Excel, and other computer applications. 

Abilities Requirement


Ability to take general direction and manage complex projects within deadlines. Must have attention to detail and the ability to organize and prioritize standard work.  

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Must have reliable transportation, with a current automobile insurance, and a current state-issues driver’s license. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands and fingers, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally life or move up to 25 pounds. Specific vision abilities required by the job includes close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus. 


Starting Salary: $66,040.00  - $84,219.20  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles