Health Services Coding Analyst (CPC Required)

Health Services Coding Analyst

Company: Wellmark
Location: Iowa or South Dakota preferred (Remote eligible)

Company Overview:
Wellmark is a mutual insurance company owned by its policyholders in Iowa and South Dakota, with over 80 years of trust. Our motivation is the well-being of our members, and we are committed to providing best-in-class service, sustainability, and innovation.

About the Role:
As a Health Services Coding Analyst, you will provide clinical leadership and subject-matter expertise to support the analysis, configuration, and administration of medical policy content within claims processing systems, including Plan General Exclusion (PGE) rules and FACETS table maintenance. You will ensure accurate implementation of medical policies, review criteria, and authorization requirements while maintaining system integrity. You will research and analyze issues, develop requirements, test solutions, and audit outcomes. This role also involves serving as an expert resource, mentoring Coding Specialists, and providing policy-related training to operational partners.

Work Hours:
Must be willing to work core business hours of 8 AM - 5 PM Central Time.

Location:
Candidates located in Iowa or South Dakota are preferred. This role is remote eligible and requires high-speed internet at the work location.

What You Will Do:

• Lead the analysis of complex medical policy content and implementation of system edits.
• Maintain claims processing system infrastructure for compliance and accurate claims adjudication.
• Translate complex medical policy language into precise coding criteria for claims systems.
• Serve as a coding subject matter expert for escalated utilization management issues.
• Collaborate with clinical teams to resolve coding-related denials, overrides, and policy interpretation questions.
• Contribute to the full lifecycle of medical policy creation, revision, and review, ensuring adherence to current coding conventions.
• Conduct impact analyses of proposed policy changes.
• Provide medical coding expertise and PGE rule knowledge to resolve complex claims and customer/provider issues.
• Monitor utilization trends to identify and resolve system configuration issues.
• Develop and optimize coding configuration standards and best practices.
• Edit, develop, and implement edits with payment integrity and analytics teams.
• Serve as a primary point of contact and Subject Matter Expert for claims processing systems (PGE rules, FACETS, STAR).
• Update coding files as required by code set revisions, regulatory requirements, and policy changes.
• Participate in cross-functional meetings to manage medical benefit expense.
• Mentor and train Coding Specialists and provide training to operational areas.

Required Qualifications:

• Certified Professional Coder (CPC) required.
• Clinical background (formal education or training in a clinical/health-related discipline, or direct work experience in a clinical/healthcare setting).
• 7+ years of related healthcare experience in provider payment, claims, medical coding, or similar.
• Demonstrated expertise and knowledge of medical coding and terminology.
• Strong attention to detail and ability to multitask.
• Strong interpersonal and communication skills (written and verbal).
• Inquisitive nature, enthusiastic about process development.
• Strong workflow management skills with a sense of ownership and initiative.
• Ability to communicate concepts clearly and motivate others.
• Proficiency in Microsoft Office applications (spreadsheets, process mapping, presentations, word processing).
• Ability to adhere to quality and production metrics.
• Experience with coaching and mentoring others.
• Demonstrated ability to consistently meet department work schedule.

Preferred Qualifications:

• Prior health plan experience.
• Associate degree or direct and applicable work experience.

Remote Eligible:
This position is eligible to work fully remote. Leaders may occasionally request in-office presence for specific meetings.

Equal Opportunity Employer:
Wellmark is committed to equal employment opportunity. Reasonable accommodation requests for disabilities should be directed to [email protected].

Work Authorization:
Wellmark is not considering applicants requiring immigration sponsorship (work authorization or permanent work authorization) now or in the future.