We are seeking a Medicare Advantage Benefits Coder to translate plan benefit designs into the coding and configuration logic used for claims adjudication. This role interprets Medicare Advantage benefits, coverage policies, limitations, and authorization requirements, then maps them to the appropriate code sets to support accurate claims processing.
Responsibilities
- Review Medicare Advantage plan documents, Evidence of Coverage, Summary of Benefits, and CMS guidance.
- Translate benefit language into claims-based coding logic using CPT, HCPCS, ICD-10, CDT, modifiers, Place of Service, Type of Bill, and related code sets.
- Create and maintain benefit-to-code mappings and configuration documentation.
- Define coverage rules, exclusions, frequency limits, prior authorization requirements, and medical necessity criteria.
- Partner with configuration, claims, clinical, and IT teams to ensure accurate benefit setup.
- Validate benefit configurations through testing and troubleshoot claims configuration issues.
- Ensure compliance with CMS regulations, Medicare coverage determinations (NCD/LCD), and payer policies.
Position Details
- Client: Healthcare Integrator Client
- Location: 100% Remote
- Contract Length: 2-month contract
- Start Date: ASAP
Requirements & Qualifications
Required Qualifications
- Experience working for a Medicare Advantage payer or health plan.
- Hands-on experience with benefit configuration, claims adjudication, or translating benefit language into coding logic.
- Strong knowledge of CPT, HCPCS, ICD-10, CDT, modifiers, Place of Service, and Type of Bill.
- Familiarity with CMS guidance, Medicare coverage rules, and medical policy interpretation.
- Strong analytical, documentation, and problem-solving skills.
Preferred Qualifications
- Medicare Advantage benefit configuration experience.
- CPC, CCS, RHIT, RHIA, CRC, CPMA, or similar certification.
- Experience with claims platforms or benefit configuration systems such as Facets, QNXT, or HealthRules.
Benefits & Perks
- Medical insurance
- Vision insurance
- Dental insurance
Location
N/A
Employment Type
Contractor
Experience Level
Senior
Remote work allowed
Yes
Posted
1 month ago