Claims Adjudication Specialist

Major Responsibilities:

• Education/Experience Required:

  Associate's degree or equivalent experience *3-5 years of healthcare Managed Care and/or Insurance environment. Including experience in claims processing / adjudication, GE / EPIC claims adjudication and knowledge of various reimbursement methodology, third party insurance administration, Medicare/Medicaid rules & regulations, guidelines and multiple reimbursement methodologies. *Basic understanding ICD9, ICD10, CPT/HCPC coding. *Must have demonstrated and sustained strong analysis and problem solving skills. *Demonstrated ability to identify and communicate issues/problems with previously processed claims and communicate root cause. *Must have demonstrated the ability to diagnosis system issues.

• EPIC Experience Preferred

  Must have Managed Care Experience

  Must have Managed Care Claim Processing Experience

• CLAIMS/REFERRAL/ELIGIBILITY RESPONSIBILITIES
  • 1)Acts as a liaison between various AHPO Departments to identify systems related claims payment/adjudication, capitation, referrals and eligibility problems and works to resolve outstanding issues.
  • 2)Resolves eligibility verification problems between HMO, PHO and AHPO. Responsible for contacting HMO and/or provider relations to obtain eligibility information. Requests fax, grids, written documentation and notifies appropriate department of eligibility status.
  • 3)Performs claim back out activities on previously processed claims if proper documentation is provided by PHO/Health Center/Provider.
  • 4)Evaluating, reviewing for appropriateness (including reaching out to providers when necessary) and determining if the claim meets regulatory requirements. Based on the determination, make necessary changes to referrals in IDX system if PHO/Health Center/AHPO identifies error in order to properly process claim.
  • 5)Coordinates information received from PHO/Health Centers to AHPO Departments, as appropriate.
  • 6)Processes special projects from claims, eligibility, referrals, finance departments.
  • 7)Reads and interprets contract language and communicates clarifications to providers and others.
• COMMUNICATION WITH ADVOCATE PHO OFFICES
  • 1)Regularly meet/discuss with Advocate Providers, PHO Directors, Medical Management and Operations Management and Representatives, regarding issues relating to AHPO processes and procedures and conducts research, follow up, and documents resolution of issues.
  • 2)Facilitates and maintains consistent correspondence with Providers and management of billing organizations while conducting research, follow up and resolution of issues.
  • 3)Serves as the primary contact for addressing large scale inquiries; displays judgment in coordinating appropriate responses.
  • 4)Identifies operational needs within the hospitals, ancillary and physician offices; implements action plans for process improvements and monitors progress.
• RECOVERY REFUND POSTINGS & RETURNED CHECKS
  • 1)Investigate refunds received are accurate then post refunds in GE.
  • 2)Identify & Report GE system issues.
  • 3)Identify & Report associate training opportunities.
  • 4)Research returned checks which requires provider outreach and ensure provider addresses are updated.
  • 5)Work with APP's Finance department on Voids, Stop Payment and Re-Issue check requests.
• MEDICAL GROUP INQUIRIES/DOI/MCR PAYMENT DEMANDS
  • 2)Run routine reports and verify intended changes were processed for COB, Grace Period and Newborn Scripting of claims in addition to running the scripts according to defined schedules.
  • 1)Research, Resolve and Respond in timely manner to Medical Group Inquiries including Department of Insurance Inquiries.

Knowledge, Skills & Abilities Required:

• *Outstanding communication and presentation skills *Ability to interpret contract language and reimbursement terms. *Ability to succeed in a changing environment and handle multiple responsibilities *Ability to work independently and prioritize assignments *Ability to problem solve and handle difficult calls/situations and maintain professionalism *Outstanding organizational skills *Experience with PC applications, word processing, spread sheets, GE.
• N/A

Physicial Requirements and Working Conditions:

• *Flexible hours including occasional weekends *Ability to work under pressure within deadlines and in stressful conditions *Ability to succeed in multi-faceted, fast paced environment with multiple priorities and applications *Self-motivated, highly organized, positive professional relationship skills, detailed with outstanding communication and presentation skills *Exceptional EXCEL knowledge required *Lead or Supervisory experience

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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