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Analyst, Claims Customer Service
3 months ago
The Claims Customer Service Analyst is accountable for and oversees the following tasks:
Manage all claims appeals, including disputes, redeterminations, and reconsiderationsConfirm reimbursement accuracy and work with Networks, Medicaid, and Medicare in any questions/concernsAnalyze claims activity and work reports received by Providers, Networks or ManagementPerform claims reprocessing, reexporting and address medical billing issuesAssist with special reports of tracking problems with medical claims according to HIPPA guidelines, contracts, fee schedules and provide education to providers/internal staff as applicableApply knowledge of coding to determine if dispute is validReview documentation, analyze reject claim data, justify CPT & HCPCS codes and pay HCFA-1500 and UB92 claims.Take inbound customer-service calls and make outbound calls to providersInvestigate pending claims and resolve discrepanciesExplains EDI claims transmissions and educates providers on rejection reasons and how to resolve the issue to ensure clean claim submissionsContacts providers to provide necessary billing guidelines to comply with quality and process standardsFollows established guidelines specific to each claim report or inquiryReview, coordinate and respond to all request or record requests in a timely orderResponsible for delivery of EOP's to providers after each claim runResponsible for investigating clearinghouse rejections, ensuring rejection letters are accurate and of high qualityResponsible for collaborating with Networks on escalating all high-volume rejection/denial claims by provider as communicated in Bi-weekly Claim Dashboards and providing an improvement plan on submission of clean claims for timely paymentsTake part in the monthly Claim Webinar Training to our NetworkESSENTIAL JOB FUNCTIONS AND DUTIESOversees review of claims inventory for quality and findings in external audits from all Payors/Providers as well as annual internal audit in accordance with PHCN Claims Policies and ProceduresHandling of all claim escalations (verbal and electronic) in accordance with PHCN Claims Policies and ProceduresEscalating all high-volume Provider Claim issues to ensure positive rapport with our network Providers in accordance with PHCN Claims Policies and ProceduresMentoring new team members and providing assistance and review of quality of work during onboardingPerform other duties as assigned within the scope of responsibilities and requirements of the jobPerforms the essential functions of this job with or without reasonable accommodationESSENTIAL QUALIFICATIONSYears of Experience and Knowledge
5 to 7 years of direct experience minimum in Claims Adjudication and Clearinghouse submissions/rejections (required)Advanced level of skills and knowledge of technical system operations (required)Detailed knowledge of medical coding; HIPPS, CPT and HCPCS codes Solid understanding of enrollment and eligibility as well as claims paying for all lines of businessSolid understanding of claim data sets required on Encounter Files to ensure resubmission of claims/disputes are in accordance to 837 CMS regulations1-3 years working in a claims inbound call center (required)Professional level training that provides a general understanding of: Administration of all contractual obligationsAudit and billing proceduresPolicies and proceduresProcessing of accounts receivable and eligibility requirements impacts claims processingVendor data feeds and discrepancy processAdministrative and regulatory requirementsTechnical workflow processesFunctional requirements of the systemSolution design documents.4 to 6 years work experience that provides a working knowledge of:Billing and delinquency proceduresAccounts receivable processSystem testing and enhancement processWeb portal data supportSkills and AbilitiesAdvanced level Microsoft Office skills (PowerPoint, Word, Outlook)Advanced level Microsoft Excel skillsAdvanced level of Web Reports and how to read 837 files to support working of encounter rejectionsInterpersonal, communication (written and verbal) and presentation skillsAnalytical, research, problem solving, and decision-making skillsAbility to monitor team goalsAbility to lead and coach team membersJob TypeFull-time tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.