Claims Specialist

Found in: Appcast Linkedin GBL C2 - 2 weeks ago

New York, United States Tandym Group Full time

A health services network in New York is currently seeking a new Claims Specialist for a promising opportunity with their growing team in Flushing.

Responsibilities:

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.
  • 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


Qualifications:

  • Bachelor's degree
  • Certified Professional Coder (a plus)

Desired Skills:

  • 3-5 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

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