Claims Specialist

4 weeks ago


New York, New York, United States CenterLight Health System Full time
Job Title: Claims Specialist

At CenterLight Health System, we are seeking a skilled Claims Specialist to support our department operations related to provider communication, pended claim review, reporting, auditing, and oversight activities to ensure compliance with all applicable State, Federal, and contractual guidelines.

Key Responsibilities:
Review claims processed by the outside vendor, including resolving provider appeals/disputes and performing root cause analysis for all provider projects to identify areas for provider education and/or system (re)configuration.
Initiate and follow through with resolution of all pended claims, (re)pricing, returned or refund checks, and the development of provider and facility compensation grids.
Provide feedback or suggestions to enhance current processes or systems.
Review and investigate claims to be adjudicated by the TPA, including the application of contractual provisions in accordance with provider contracts and authorizations.
Compile claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner.
Investigate suspense conditions to determine if the system or procedural changes would enhance claim workflow.
Communicate and follow 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.
Analyze patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions.
Validate DRG grouping and (re)pricing outcomes presented by the claims processing vendor.
Attend JOC meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines.
Assist TPA with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processing.
Ensure that refund checks are logged and processed, enabling expedited credit of monies returned.
Analyze check return/refunds volumes and trends to determine root causes. Propose workflow changes to correct and enhance claim processes to prevent returned checks/refunds.
Generate routine daily, monthly, and quarterly reports used for managing process timeframes and vendor productivity, ensuring compliance with all regulatory requirements and contractual vendor SLAs.
Participate in special projects and perform other duties as assigned.

Qualifications:
Bachelor's degree
Certified Professional Coder (a plus)
Eight or more 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.
Salary Range: $60,000.00 - $65,000.00
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