Expert Reimbursement Resolution Specialist

1 week ago


New York, New York, United States MetroPlusHealth Full time

About MetroPlusHealth

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MetroPlusHealth is a leading healthcare provider dedicated to empowering New Yorkers by uniting communities through care. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, we are committed to building strong relationships with our members and providers to enable them to live their healthiest lives.

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Job Overview

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We are seeking an Expert Reimbursement Resolution Specialist to join our team. This role will be responsible for investigating and resolving high-level claims-related issues, utilizing deep knowledge of various reimbursement methodologies.

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Key Responsibilities

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  • Improve engagement between the Plan and Hospital Network, Ancillary, and Community providers by providing timely resolution of issues and exceptional customer service and support.
  • Demonstrate a detailed understanding of various reimbursement methodologies, including skilled nursing facilities, medical groups, post-acute bundles, etc.
  • Conduct audits to review accuracy of cost reports and payment of claims.
  • Review inquiries from providers regarding cost report settlements.
  • Research and analyze claim processing outcomes, identify issues, and report as necessary, and proactively outreach to peers, supervisor, and/or providers upon findings.
  • Prepare and analyze cost/business proposals and reports of findings; make recommendations to management.
  • Apply knowledge of established procedures to research and resolve escalated customer questions or management requests.
  • Act as the initial contact for escalated issues from the support staff and escalate only the most complex issues to the immediate supervisor.
  • Liaise between Finance, Network Operations, Claims, UM, Provider Maintenance, Core, and Contracting departments to resolve ongoing issues and determine root cause and ultimate resolution of issues.
  • Review system setup to determine if it reflects contract language and outreach to the Contracting Department for assistance.
  • Attend Joint Operating Committee meetings and take ownership of resolving issues with assigned hospitals, etc.
  • Contribute to development of policies and procedures, process improvement initiatives.
  • Perform other support activities and duties as assigned.
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Requirements

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  • Bachelor's degree required.
  • 3-5 years of experience in a managed care government program claims processing/analyzing experience, working with providers in addressing reimbursement issues.
  • Or Associate Degree with 5-7 years or more experience in a managed care government program claims processing/analyzing experience, working with providers in addressing reimbursement issues.
  • Ability to work independently to meet deadlines.
  • Working knowledge of and proficiency with Windows-based PC systems and Microsoft Word, Outlook, Excel, PowerPoint, and SharePoint.
  • Ability to exercise tact and diplomacy and demonstrate strong customer service skills.
  • Ability to prepare written and oral reports and make effective presentations.
  • Ability to independently manage assigned workload, make decisions related to area of functional responsibility, and recognize issues requiring escalation.
  • Highly organized, detail-oriented, dependable, and professional individual.
  • Ability to travel to meet with Providers and their representatives.
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Salary Information

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The estimated annual salary for this position is $95,000 - $115,000, depending on qualifications and experience.

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Contact Information

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Please submit your application and resume to apply for this exciting opportunity to join our team.

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About Us

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MetroPlusHealth is a leading healthcare provider dedicated to empowering New Yorkers by uniting communities through care. We believe that healthcare is a right, not a privilege, and are committed to making a positive impact in the lives of our members and providers.



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