Claims Specialist

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

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

• 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