Claims Specialist

in Healthcare Contract

Job Detail

  • Experience Level Mid Level
  • Degree Type Bachelor of Arts (BA)
  • Employment Temporary
  • Working Type Hybrid
  • Job Reference 0000007800
  • Salary Type Hourly
  • Industry Healthcare
  • Selling Points

    Seeking a Claims Specialist for a hybrid role in Queens, NY.

Job Description

Summary:

The Claims Specialist will support department operations related to provider communication, pended claim review, reporting, auditing, and oversight activities to ensure compliance with all applicable State, Federal, and contractual guidelines.

 

RESPONSIBILITIES:

         The Claims Specialist will be responsible for reviewing claims processed by the outside vendor, including resolving provider appeals/disputes. Performs root cause analysis for all provider projects to identify areas for provider education and/or system (re)configuration. Initiates and follows through with resolution of all pended claims, (re)pricing, returned or refund checks and the development of provider and facility compensation grids. Provides feedback or suggestions to enhance current processes or systems.

         Reviews and investigates claims to be adjudicated by the TPA, including the application of contractual provisions in accordance with provider contracts and authorizations

         Compiles claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner

         Investigates suspense conditions to determine if the system or procedural changes would enhance claim workflow

         Communicates and follows up with a variety of internal and external sources, including but not limited to providers, members, attorneys, regulatory agencies, and other carriers on any claim related matters

         Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions

         Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor

         Attends JOC meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines

         Assists TPA with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processing

         Ensures that refund checks are logged and processed, enabling expedited credit of monies returned

         Analyzes check return/refunds volumes and trends to determine root causes. Proposes workflow changes to correct and enhance claim processes to prevent returned checks/refunds

         Generates routine daily, monthly and quarterly reports used for managing process timeframes and vendor productivity, ensuring compliance with all regulatory requirements and contractual vendor SLAs

         Participates in special projects and performs other duties as assigned 

 

QUALIFICATIONS:

 

  Bachelor's degree. Certified Professional Coder (a plus)

         Eight or more years of insurance experience within a healthcare or managed care setting (preferred)

         Claims adjudication experience

         Knowledge of MLTC/ Medicaid/Medicaid benefit 

         Knowledge of Member (Subscriber) enrollment & billing

         Knowledge of Utilization Authorizations

         Knowledge of Provider Contracting

         Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS

         Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software

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