COST CONTAINMENT ANALYST III

As a Cost Containment Analyst youll be serve as support to the Claims team by handling transplant cases (including benefit verification, & claims processing), the Dialysis Program and specialized dialysis pricing, as well as complex claim calculations. Cost Containment also handles appeals, claims adjustments/refunds, Medicare pricing, processing of fees, refund recovery, claim edit verification, OON negotiations, subrogation, Cost Comparison Program, and bill reviews for the medical department. Key responsibilities include:

• Reviews and researches appeals / disputes and provides a written response in a timely manner.
• Calculates adjustment payments of benefits in accordance with coverage information, contract language or plan document, and medical documentation.
• Calculates overpayments and requests refunds of benefits in accordance with coverage information, contract language, or plan document and medical documentation.
• Posts refunds of overpayments in the system and provides a written response to the client or provider.
• Calculates pricing affected by partially denied services.
• Recognizes all parts of a UB04 and HCFA1500 to accurately price to Medicare.
• Reviews transplant contracts and processes related transplant claims according to the transplant program.
• Processes variety of fees, including but not limited to: negotiations, savings, IRO, & PBM.
• Determines and documents primary / secondary status of members who are eligible under the Dialysis Program.
• Communicates clearly with clients, participants, brokers, vendors, and others within the department and company regarding any of their assigned duties.
• Meets monthly quality standards and production goals.
• Performs other duties as assigned.

Requirements

• High school diploma or equivalent.
• 2 years of claims processing experience.
• Knowledge of CPT, HCPCS, ICD9, ICD10 coding.
• Knowledge of claims processing.
• Knowledge of Eldorado system preferred.
• Knowledge of professional customer service practices.
• Skill in interpersonal and written communication.
• Ability to work independently.
• Ability to solve problems and analyze information.
• Ability to adapt to a constantly changing environment.
• Ability to multi-task.
• Ability to accurately compile data and perform detailed work.
• Ability to meet deadlines.
• Ability to maintain regular attendance.
• Ability to maintain confidentiality of material and information.
• Ability to maintain professional appearance and demeanor.
• Ability to work as a member of a team.
• Must be able to remain in a stationary position for 80% of the time.
• Must use close visual acuity to perform an activity such as: preparing and analyzing data and figures, transcribing, viewing a computer terminal and expansive reading.
• Must be able to lift or move items up to 20lbs.
• Must have the ability to move files, open filing cabinets and bend or stand as necessary.