Health Plan Coding Contractor

Health Plan Coding Contractor

Primary Responsibilities
As a Health Plan Coding Contractor, you will be retained as a subject matter expert (SME) to provide specialized, high-impact support for health plan coding, focusing on strategic client implementations and complex benefit structures. This role is a contract assignment emphasizing rapid deployment, deep technical skill, and direct ownership over the integrity, compliance, and accuracy of high-priority plan builds.

Key Deliverables and Responsibilities

I. Technical Expertise and Quality Assurance

• Deep-Dive Validation: Conduct rigorous review and validation of health plan coding for accuracy, consistency, and alignment with client-specific benefit designs and regulatory standards (e.g., ERISA, ACA).
• Complex Coding Translation: Serve as the primary resource to translate complex Summary Plan Descriptions (SPDs) and Evidence of Coverage (EOC) into accurate, consistent, and compliant coding configurations within the benefit platform.
  • Directly participate in coding the claim adjudication system.
• Proactive Audits & Compliance: Conduct proactive and scheduled audits of coded benefits to ensure completeness, proper application across platforms, and adherence to all regulatory and contractual obligations.
• Edge Case Resolution: Provide definitive coding expertise and guidance on edge cases and highly complex benefit structures to internal stakeholders (e.g., Member Claims, Care Navigation) to resolve processing issues.
• Workflow Integration (MCA Focus): Lead the cross-functional process with the MCA team to track updates to benefit builds, which includes:
  • Creating specific pend rules to stop all impacted claims.
  • Performing manual review to ensure correct processing and tracking results.
  • Defining the critical mass threshold for removing the pend rule and allowing claims to process freely.

II. Collaboration and Continuous Improvement

• Implementation Partnership: Partner closely with Product, Implementation, and Client Experience teams to ensure code-level accuracy and seamless execution during all plan builds, change cycles, and go-lives.
• Knowledge Transfer: Document all coding resolutions and complex configurations, supporting the transfer of institutional knowledge to full-time staff to ensure long-term stability after the contract period.
• Optimization: Support continuous improvement efforts by identifying and recommending specific areas of coding optimization, automation, and tooling enhancements.
• Education: Communicate and educate internal departments on upcoming and impactful coding updates ad hoc , as required by project needs.

Required Qualifications and Experience

• Mandatory Payer/TPA Experience (3+ Years): REQUIRED 3+ years of direct, hands-on experience in a Third-Party Administrator (TPA) or Payer setting focusing specifically on health plan coding, benefit configuration, or claims system setup.
• Active Coding Credential: Must hold an active coding credential from a recognized national organization (e.g., AAPC, AHIMA).
• Benefit Platform Proficiency: Proven ability to navigate and interpret complex plan documentation and strong analytical experience working in enterprise benefit platforms (e.g., Facets, QNXT, HealthRules, or similar TPA/Payer systems ).
• Technical Acumen: Demonstrated expertise in translating complex benefit logic into code and performing root cause analysis on processing errors.
• Independent Delivery: Proven ability to work independently on high-priority assignments, manage time effectively, and deliver results against tight project deadlines.
• Excellent attention to detail with a focus on accuracy and impact.