Claims Specialist

• 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 

• 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

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
• Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
• Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (Language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

• Immediate enrollment in Health Insurance
• Dental Insurance
• Life Insurance
• Employee Assistance Program (EAP)
• Access to Investment Accounts
• Career and educational tools within our Ingenovis ACT (Advocacy) Program

Salary : $22 - $26