Claims Adjudication Specialist
4 weeks ago
MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Position Overview
This position is responsible for the data entry and system adjudication of provider claims including but not limited to professional, ancillary and facility claims. The position is responsible for the end-to-end processing of claims.
Job Description
- Process claims involving medical and/or surgical services; screens for complete member/provider information
- Conducts end-to-end processing including ensuring claims are processed timely and accurately in accordance with the system configuration.
- Assists with the user acceptance process for fee schedule and contract configuration
- Applies administrative policies when necessary, utilizing the claims processing manuals
- Generates letters/questionnaires to providers to obtain additional information
- Responds to internal and external claims related inquiries (written, telephonic and portal) in a timely and compliant manner
- Processes claims adjustments
- Conducts research to identify root cause analysis
- Manages daily claims pended and production inventory
- Research and resolve inquiries/issues initiated internally (i.e., finance), also by mail, telephone, portal, fax and internal transfers including recoupments, refunds, adjustments and
reconsiderations. - Documents, tracks and reports on issues and inquiry resolution
- Reviews descriptions of services on claims to determine validity of charges of the presence of errors
- Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies
- Conducts pre and post adjudication review of claims to verify accuracy of processing
- Maintains production and quality goals established for the department
- Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars
- Associates Degree required; and
- Minimum 1 year' experience in claims operations with knowledge of integrated claims processing; or
- A satisfactory equivalent combination of education, training, and experience
- Proficiency with data entry
- Through knowledge of medical terminology, CPT, ICD-p, and Revenue Codes
- Integrity and Trust
- Customer Focus
- Functional/Technical skills
- Written/Oral Communication
#LI-Hybrid
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