Medicare Secondary Payer Specialist

Position Description

The position processes Medicare Secondary Payer (MSP) inquiries, emails, and claims, which includes all aspects of MSP primacy determination and the FACETS system utilizing established policies and procedures to review and correct error and warning messages. Utilize various tools within the FACETS system and other Capital systems to research claims to ensure proper adjudication. Partner with other Capital departments and Capital vendor partners, as needed, to complete claim adjudication. Correspond with Medicare (CMS) and group leaders to process Medicare Demand Notices, utilizing the CRC Portal to ensure timely processing. Correspond with CPR and Analyst to complete Section 111 reports, including Query Only file, TIN Response file, and other responsibilities that deem appropriate. Must perform all duties in compliance with HIPAA regulations.

Responsibilities and Qualifications

Duties and Responsibilities:

• Adjudicate pended claims and adjustments in FACETS by researching and resolving error and warning messages within established timeframes.
• Section 111 responsibilities
• Communicate with internal business partners, Medicare, group leaders and providers to obtain/provide information as needed to ensure proper claim/adjustments/demand notice adjudication.
• Review and take necessary action as needed in response to inquiries from internal business partners, through Facets inquiries, e-mail, and paper correspondence.
• Perform outreach (both verbal and written) to other insurance companies, providers, group leaders, and Medicare, Enrollment & Billing, as needed to obtain additional information to process claims/adjustments/ Demand Notices.
• All other duties and assignments as directed.

Skills:

• Must possess a strong attention to detail and an interest in preventing errors
• Demonstrate critical thinking, problem solving, and decision making abilities
• Demonstrate ability to be independent, self-sufficient, dependable and professional
• Demonstrate intrinsic initiative and time management skills
• Must possess a strong commitment to teamwork and an ability to foster an inclusive culture of diversity by working well and collaborating with others as needed
• Ability to thrive in a dynamic working environment, multi-task, and adapt quickly
• Ability to accept feedback, learn, and adapt from guidance to be successful
• Ability to mentor peer group in best practice standards as well as positively spread continuous changes to processes and the responsive health care environment
• Must demonstrate effective verbal and written communication
• Ability to adapt to constant changing priorities and keeping daily responsibilities on task
• Ability to manage workload and ensure all tasks are completed within established timeframes
• Must be willing and able to work possible mandatory overtime as needed based on business needs
• Foster an inclusive culture of diversity, working well with others
• Must be able to meet quality, productivity, and behavior expectations

Knowledge:

• Knowledge and familiarity with claims processing, FACETS, Work Desk, and HIPAA policies and regulations preferred
• Familiarity with Provider and Subscriber billing documents and applicable billing terminology preferred
• Ability to operate a personal computer (PC) and other office equipment (e.g., copy machine, fax machine, printer, calculator, and etc.) as well as possess excellent keyboarding skills
• *Demonstrated competency in the use of computer applications, databases, and end user computing tools and programs, including proficiency in various software like Microsoft Windows, Email, Internet browsers, Instant Messenger, and Office (Word, Excel, etc.)
• Must possess basic reading and arithmetic skills (reading and math comprehension)

Experience:

• FACETS claims Coding
• Facets claims processing
• FACETS adjustments
• Basic understanding of Medicare Secondary Payer (MSP)

Education and Certifications:

• Must have a high school diploma or GED.

Work Environment:

Operations center environment!!Qualified candidate must be able to work a set shift schedule M-F during normal business hours. Weekend overtime hours may be required at times based on business needs. !!Full-time candidates may be eligible to work at home pending corporate and department eligibility criteria, review, and approval of a work at home request

Physical Demands:

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see!!The employee must be able to work over 40 hours per week!!The employee must occasionally lift and/or move up to 5 pounds