Medical Claims Analyst-MCO (Hybrid)
Responsible for providing the Director of Claims Administration with analytical support necessary to ensure regulatory and business, claim administration, compliance. Primary responsibilities include improving the quality of reporting and data by working with TPA to identify reporting needs, defining report specifications, and developing reports to meet user needs. Assisting, organizing, and participating in projects that will improve or enhance business outcomes that includes but is not limited to increasing the level of automation, problem identification and resolution, improving work-flows and procedures, developing or revising appropriate documentation, unit and system testing. Provides assistance in handling claim related calls from the provider community. Responding to claim related inquiries via email. Analyzing claim data to respond to pending claims in the claims adjudication system.
- Improve the quality of reporting and data by working with the user community to identify reporting needs, defining report specifications, and developing reports to meet user needs
- Prepare user documentation, as required.
- Analyze data, summarize findings, and report results using profile practice patterns, capitation rates, etc.
- Develop and monitor data analysis used for negotiating and evaluating contracts
- Provide analysis of business functions for optimum business functionality and/or design, workflows and documentation to improve efficiency.
- Create action plans based on research performed and communicate recommendations, to senior management, for system and / or process changes to address current business needs and follow through with plan to implementation.
- Evaluate system coding to validate pricing and claims payments to ensure claims are processed in accordance with provider contracts, member benefits, and authorization requirements.
- Evaluate inpatient facility claim payments to ensure accuracy using the DRG grouper and pricer as well as comparing authorizations to claim payments.
- Evaluate outpatient facility claim payment to ensure accuracy using the APC grouper and pricer as well as comparing authorizations to claim payments.
- Analyze claims and data to improve operational efficiency, productivity, and accuracy.
- Act as a subject matter expert for claims system functionality and capabilities.
- Identify training issues and assist in the development of policies and procedures and training materials to clarify issues and increase accuracy and timeliness of processing.
- Handle provider claim inquiries.
- Manage underpayment / overpayment recovery processes to ensure claims are reprocessed in a timely manner.
- Monitor mis-paid claims, develop, and implement ongoing tracking mechanism and recommend activities to reduce / avoid mis-paid claims from re-occurring.
- Participate in continuous improvement activities.
- Provide Education to providers/vendors on correct billing methodologies.
- Monthly audits of EOBs and EOPs for compliance with CMS regulations.
- Monthly audits verifying that claims are being paid in accordance with provider contracts.
- Manage claims inquiries and individual Provider requests.
- Auditing capitated providers to ensure encounter data is being submitted timely
- Work on other activities and /or projects as requested by management.
- Bachelor’s degree in Computer Science, Information Management Systems or related field or 5+ years equivalent and relevant experience preferred.
- 5 medical claims processing, claim reimbursement, provider reconciliation, and regulatory Medicare and Medicaid, experience required
- At least 3 years experience in management analysis capacity