- Responsible for data collection and analysis regarding provider inquiries and/or disputes or other trending payment integrity activities
- Acts as point of contact for submission and/or resolution of denial determinations and provider disputes. Interfaces with internal stakeholders regarding reconsiderations, disputes and/or appeals as appropriate
- Research and documents denial determinations at all levels of provider disputes in a thorough, professional, and expedient manner
- Coordinates workflow between departments and interfaces with internal and external resources
- Composes all correspondence and dispute information concisely and accurately, in accordance with regulatory requirements
- Supports the development and standardization of business rules documents including appropriate trend reporting
- Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all provider disputes
- Monitors each dispute to ensure all internal and regulatory timelines are met
- Provides re-enforcement training for new and existing associates as needed
- Work with contracting, provider relations and configuration teams when inconsistencies are found
- Collaborate with internal and external stakeholders to ensure prompt and appropriate action is taken regarding cost avoidance/cost containment activities
- Conducts regulatory research to determine revisions/updates to various federal and state payment requirements for hospital, ambulatory surgery, and physician providers
- Consults and coordinates with various internal departments, external resources, business partners, and government agencies as appropriate
- Works closely with clinical personnel to ensure alignment with clinical and benefit policies
- Reviews technical documents and specifications for compliance with operational procedures
- Ensures safe care to patients, staff, and visitors; adheres to all Apex policies, procedures, and standards within budgetary specifications including time management, supply management, productivity, and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.
- Three (3) years of experience working in a healthcare data or regulatory environment; payment integrity and claims experience preferred.
- Effective oral and written communication skills.
- Knows how to obtain and use data and is comfortable with statistical concepts.
- Strong interpersonal skills to work with all levels across all functional areas to include internal business partners.
- Strong understanding of regulatory requirements and reporting related to claims processing including Texas Department of Insurance and CMS.
- Expert understanding health care claims data, pricing and claims editing concepts, including UB04 and HCFA 1500 claim content for varying business lines including Medicare Advantage, Commercial Fully Insured, Medicaid, etc.
- Experience with Microsoft Word, Excel, PowerPoint, Visio.
- Preferred systems knowledge – Facets, NetworX Pricer, CES, Tableau.
- Ability to solve practical problems and deal with a variety of variables in situations where information may be limited.
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Claims Analyst - Houston, United States - Apex Health Solutions
Description
Job Description
Job DescriptionSummaryClaims Analyst is responsible for accurate and timely research of all providers claim inquiries according to policies, process instructions and system requirements, regulatory reporting, and acts as a liaison between internal stakeholders for associated claims processes. Candidate will respond to all incoming inquiries and coordinate with other internal and external stakeholders to resolve the issue, determine the underlying cause and make recommendations regarding system changes that may be relevant.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
Minimum Qualifications
Education: High School diploma; Bachelor's in business or health care field preferred
Licenses/Certifications: (None)
Experience / Knowledge / Skills:
