This position is responsible for leading a specialized team of Claims Analysts who ensure timely and accurate claim payments.
Essential Duties and Responsibilities:
Oversight of pre-payment audit reporting and payment posting process to ensure accuracy of payments being made to providers and facilities.
Ensures that Virtual Examiner (VE) reports are optimized based on contracts and used to apply the appropriate edits which result in financial savings.
Creates claim adjustments, retro adjudications due to rate changes, and reprocessing projects identified during the internal audit process.
Request and post claim payment refunds and recoup overpayments as necessary.
Reviews all identified over/under payments to determine whether claims payment discrepancies are due to system configuration, training issues or erroneous claims processing.
Responsible for coordinating and ensuring accurate and timely completion for testing of benefit design, contracts, and all claims related system updates and upgrades.
Monitor and ensure that all Customer Relationship Management (CRM) requests and inquiries to the analyst email distribution list are completed in a timely manner.
Responsible for first level claim appeals processing in accordance with contractual requirements.
Applies accurate principles, policies, procedures and regulations, including: benefit interpretation, Coordination of Benefits (COB), deductibles, co-insurance and out of pocket maximums to the adjudication process.
Regularly trains, assigns, coordinates, and reviews the work of staff.
Assists with projects and internal or external audits as needed.
Processes professional claims, facility claims, ad hoc vendor payments and member reimbursement requests as needed.
Demonstrates knowledge and understanding of all systems, product lines benefit levels, capitation and discount agreements.
Create and keep current internal Standard Operating Procedures and reference tools, providing related training to team members.
Responsible for identifying efficiencies and recommending process improvements to increase auto-adjudication rates and reduce manual processes.
Maintains courteous, helpful and professional behavior on the job and displays a willingness and ability to be responsive in a warm and caring manner to all customer groups.
May perform other duties as assigned.
Skills and Abilities:
Must maintain a good rapport and cooperative working relationship with internal and external customers.
Ability to promote teamwork and cooperation.
Able to work independently with minimal supervision.
Adhere to time and attendance policies.
Ability to maintain composure under pressure.
Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.
Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
Ability to write speeches and articles for publication that conform to prescribed style and format.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Work Schedule:
As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 15 pounds.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.
Qualifications
High School or general education degree (GED); and five to seven years related claims experience and/or training. Associate degree preferred.
Medical Coding Certification- CPC or equivalent preferred.
Must have familiarity with ICD10-CM, HCPCS level II and III, CPT, revenue codes, and DRG coding on UB-04 and CMS 1500 claim types.
Able to train staff through written, verbal and demonstration methods.
The person in this role must possess a high level of expertise with medical claims processing/adjudication workflows, fee schedules, contract terms, coverage and reimbursement policies and claims processing standards.