Claims Specialist - New York, United States - RSC Solutions

Description

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, (re)pricing, returned or refund checks and the development of provider and facility compensation grids. Provides feedback or suggestions to enhance current processes or systems.

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

Experience:

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