Claims Specialist - Tandym
New York, NY
About the Job
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
Qualifications:
- Bachelor's degree
- Certified Professional Coder (a plus)
Desired Skills:
- 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
Source : Tandym