What are the responsibilities and job description for the Member Balance Billing DMR Specialist position at SCAN Health Plan?

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 , , 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

Preferred, but not required : Associate degree in business administration, Health Care Management or similar field of study.

A comparable combination of education / experience and / or training will be considered equivalent to the education listed above.

5 years Managed Care experience with Medicare and Medicaid, prefer Medicare Advantage experience

3 years’ experience in claims examination, including documentation and summarization, for professional, institutional, and ancillary service claims.

2 years’ experience with member facing activities such as call center or advocate services.

HMO and / or PPO experience.

Knowledge of all medical coding types (CPT, ICD 10, HCPC, etc.), certification preferred

Ability to create an industry standard claim from billing statements, medical records, etc., using standard codes, interpretation of documents and system resources.

Knowledge of HIPAA regulations and privacy laws.

Expert knowledge of healthcare coding including CARCs / RARCs, HCPCS / CPT codes, ICD-10s, RBRVS, DRG, APC, etc.

Strong interpersonal skills, including excellent written and verbal communication skills.

Ability to take initiative in identifying problems, developing solutions, and taking elevating issue to leadership.

Ability to think and work effectively under pressure and accurately prioritize and complete multiple assignments within established timeframes.

Ability to appropriately maintain confidentiality.

Strong analytical and critical thinking skills, required.

What’s in it for you?

Base Salary range : $ - $

An annual employee bonus program

Robust Wellness Program

Generous paid-time-off (PTO)

Eleven paid holidays per year, plus 1 additional floating holiday

Excellent 401(k) Retirement Saving Plan with employer match.

Robust employee recognition program

Tuition reimbursement

A work-life balance

An opportunity to become part of a team that makes a difference to our members and our community every day!

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