Concept Implementation Specialist

Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit, and regulatory teams to get accuracy right from the start—when it matters most. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care, and improving access for all. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense. We geek out over building and perfecting software that helps health plans succeed, but we also understand the irreplaceable value of human intelligence. Penstock is an Equal Opportunity Employer.

Role and Responsibilities

The Concept Implementation Specialist is a subject matter expert who is a member of the team responsible for the ideation, development, maintenance, and use of Penstock selection logic for all claims, provider, and review types. This position works directly with the Senior Director of Concept and Edit Implementation, members of the Concept/Edit Development team, Audit team, Project team, and IT team to ensure that Penstock claims selection is accurate and effectively meets client deliverables by identifying coding, billing, and documentation errors that result in improper payments.

• Participates in the concept development process which includes, but is not limited to, researching concepts, contributing to the creation of claim selection algorithms and validating results, writing review criteria and rationale, and creating audits in the production environment.
• Research federal and state rules and regulations, payor medical and administrative policies, provider contracts, and coding and billing standards to develop claim recovery opportunities specific to a multitude of payment methods.
• Assists with the development and maintenance of applicable code sets for new or existing Penstock edits as well as builds, tests, and implements the edits.
• Works with IT when changes or modifications are identified, or when functionality of the Penstock edit language is compromised.
• Helps prepare and deliver training materials for new audit concepts to the Audit team.
• Helps develop, and utilizes, tools for analyzing, reporting, and continuously improving concept performance.
• Analyzes audit results, identifies edit revision requirements, and makes revisions when appropriate.
• Assists with monthly claim selection process as needed.
• Provides thoughtful, helpful, and inspiring support to the Audit and Concept Development teams.
• Learn new reimbursement methods as needed.
• Keeps abreast of coding, clinical, and other industry changes that impact Penstock selection logic and/or suggest new concept opportunities.
• Provides input for the continuous enhancement of the Penstock audit software.
• Attend internal and external meetings as needed as a Concept Development SME.
• Serves as a Payment Integrity SME for Audit and Concept Development team members and for the Goodroot organization as a whole.
• Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater integrity between payors and providers.

Qualifications and Education Requirements

• Bachelor’s Degree in Health Informatics or Health Information Management, or equivalent formal education and experience
• Current AHIMA or AAPC coding credential(s)
• 5 or more years of coding and/or auditing experience (or demonstrated equivalent)
• Experience with reimbursement policies and methodologies across different settings, such as inpatient, outpatient, skilled nursing, professional, etc.
• Experience with reviewing and interpreting federal and state rules and regulations, payor medical and administrative policies, provider contracts, and coding and billing standards
• Comprehensive understanding of Official Coding Guidelines, AHA Coding Clinic, and CPT assistant
• Experience, or familiarity, with structured query language (SQL) preferred
• Experience with collecting, analyzing, and interpreting claim and audit data
• Understanding of HIPAA, and all rules and practices regarding the safeguarding of PHI/PII
• Ability to communicate kindly and effectively with all levels of the organization
• Experience training, preparing, and delivering presentations
• Proficient with Microsoft Word, Excel, and PowerPoint
• Able to work Eastern time zone hours
• Secure and private home office with reliable high-speed internet connection