What are the responsibilities and job description for the Member Balance Billing DMR Specialist position at HealthCHEC?
MBB DMR Specialist
Remote
About SCAN
SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided with in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.
The job
Responsible for review, determination, and finalization of claims received from members who paid for services and are seeking reimbursement. This role will make decisions based on the member's Evidence of Coverage and the parameters of the DMR program to determine if reimbursement is allowed then accurately price the claim based on Medicare reimbursement pricing tools. Shall evaluate and understand medical documents to properly code and decision a claim. Strong ability to make independent decisions on medical information as to the urgent or emergent nature of the service to align with the program parameters and ability to engage medical resources internally to assist in decision making. Confidence communicating to members and internal resources when necessary.
You will
- Evaluate medical records, billing documents, and payment documentation to make appropriate determination on the claim.
- Use system to correctly code claims / adjust coded claims with industry standard codes based on documentation submitted.
- Determine validity of member request then communicate the decision to the member through written documentation or, verbally, where necessary.
- Evaluate the need to forward claim to other teams to support claim adjudication as necessary.
- Calculate proper reimbursement amounts based on system pricing tools, Medicare pricing, and member cost share.
- Ability to use multiple systems to complete claims research and processing.
- Strong written and verbal skills to communication and document claim information.
- Critical thinking skills to interpret member requests, when to engage others to assist in medical review, method of communication with members.
- Identify areas of DMR program for improvement and communicate a plan for change to Claims leadership.
- Participate in documentation development for Claims and other internal teams to define the DMR program.
- Actively support the achievement of SCAN's Vision and Goals.
- Other duties as assigned
Your qualifications
What's in it for you?
An opportunity to become part of a team that makes a difference to our members and our community every day!
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
LI-AC1
Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Salary : $22 - $35
