Medical Claim Specialist Supervisor (WHWC)

Department Description :

Claims processing department is responsible for repricing and processing of specialty referral services, medical, dental, medical lab, and diagnostic claim forms for allocation of payment.

Essential Duties :

• Responsible for coordinating and supervising the day-to-day operations of the Claims Processing function, ensuring work is completed in a timely and accurate manner.
• Maintain organizations compliance with billing guidelines set by the Centers for Medicare Services.
• Annually analyze contract terms to ensure all parties are still adhering to current contractual agreed upon terms.
• Supervises Medical Claims Specialist; oversees daily operation of team, assists in collection of time and attendance reports, conducts staff development, coaching as needed, manages assigned workloads and team member performance, ensures compliance with company processes, policies, and directives, maintains safe working environment.
• Contributes to content and data for reports, prepares, and develops modifications and recommendations for department leader review and approval.
• Participates in hiring for positions within the Patient Services Department.
• Monitors supplies, program materials, and arranges equipment maintenance.
• Performs yearly team member evaluations.
• Conducts monthly rounding for all direct reports.
• Submits monthly reports to Manager.
• Responsible for training team members, temporary workers, and work study interns.
• Proven ability to coach, mentor and lead fellow team members on department process and procedure.
• Responsible for collecting data for monthly reports.
• Process Medical, Specialty Referral, and Dental Claims and invoices.
• Read, analyze, understand, and ensure compliance with claims / invoicing process.
• Verify approved appointments, approved diagnostic and / or procedures, follow-up care.
• Coordinates and communicates with external and interdepartmental teams to ensure accuracy of claim / invoices to review approved CPT Codes.
• Verifies, processes, and / or adjudicates claims, including applying detailed consideration, standards in claim / invoices for proper application of department policy related to claim entry and analysis; with duties including but not limited to high visibility and sensitivity claim levels.
• Resolution of claims disputes.
• Independently reviews, analyze, and make determinations of claims for : 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
• Review, analyze and reprice claims to approved MHM contracted rates.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Proficient in medical coding and medical terminology.
• Ensures timely and proper arrangement of claims in accordance with coverage amounts.
• Analyze claims for billing inconsistencies and medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Composes and submits denial letters, develops write off letters and confirms services per contracted agreements.
• Proficient knowledge of Microsoft Suite.
• Review claim reports to finalize all claim determinations timely.
• Data entry of claim and Explanation of Payment information.
• Maintains patient confidentiality and complies with all federal and state health information privacy laws.
• Proficient in claims software and Electronic Health Records.
• Understanding and familiarity of HIPAA guidelines
• Performs other duties as assigned.

Qualifications :

Individual must be able to perform each essential duties. The requirements listed above are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Skill Development :

Strong verbal and written communication skills, attention to detail, customer service, interpersonal, time management and critical thinking skills.

Education / Experience :

High school diploma or general education degree (GED) required. Minimum 1 year claims processing experience preferred.

Language Ability :

Ability to read, analyze and interpret documents and write detailed correspondence. Ability to provide excellent customer service and to effectively communicate with internal team members and external stakeholders.

Reasoning Ability :

Ability to interpret and carry out instructions furnished in written, oral, and diagram form.

Must understand processes, define problems, collect & interpret data, facts, and obtain valid conclusions.

Mature reasoning skills, demonstrated by consistent professionalism, with an ability to identify and address organizational needs, develop, and justify recommendations, and be responsive and clear in interacting with individuals at all levels, both internally and externally.

Work Environment and Physical Demands :

The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the team member is exposed to a medical office environment. The position necessitates bending, stooping, twisting, turning, walking, climbing step stools, sitting, and standing for periods of time. Must be able to lift and maneuver 25 pounds.