American Health Partners

Medical Billing and Coding

• Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes
• Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS for reimbursement
• Interpret medical documentation to ensure all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives is captured
• Develop tools and metrics to improve accuracy and completeness of coding and documentation
• Provide a high level of customer service to internal and external clients by meeting and/or exceeding expectations including quality and productivity standards
• Escalate appropriate coding audit issues to management as required
• Participate in and support ad-hoc coding audits as needed
• Support ongoing programs which minimize organizational risk in the event of a Risk Adjustment Data Validation (RADV) Audit
• Work assigned coding projects to completion
• Other duties as assigned

Medicare Risk Adjustment Coding Specialist

Billing Specialist

• Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting
• Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time
• Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment
• Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines
• Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff
• Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers
• Serve as primary billing and claims contact for contracted network and long-term care pharmacies
• Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues
• Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes
• Support transitions of care by ensuring medication access and clean claim processing for new or discharged members
• Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies
• Accurately document all claim interventions, communications, and resolutions in the plan’s system
• Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing
• Identify trends in claim rejections or PA delays and escalate systemic issues to leadership
• Monitor daily billing and claims work queues and meet productivity and turnaround time expectations
• Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams
• Support process improvement initiatives to enhance claims efficiency and member access to medications
• Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing
• Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes
• Coordinate clinical reporting
• Follow-up and solve open items in a timely manner
• May be assigned to work on special projects and business initiatives

Pharmacy/Billing Technician

• Conducting coding audits prior to payment release.
• Performing post-payment coding reviews with overpayments.
• Sending coding education correspondence to applicable providers.
• Reviewing medical records, patient medical history and physical exams.
• Assisting with validation audits to evaluate medical record documentation.
• Interpreting medical documentation to ensure coding captures HCC conditions.
• Developing tools and metrics to improve coding and documentation accuracy.
• Providing high level of customer service to internal and external clients.
• Escalating appropriate coding audit issues to management.
• Participating in and supporting ad-hoc coding audits as needed.
• Supporting ongoing programs to minimize organizational risk in RADV Audits.
• Completing assigned coding projects.
• Other duties as assigned.