Northwell Health

FlexStaff is seeking a Temporary Claims Specialist for our client, a non-profit healthcare organization providing home and community-based healthcare and services for the elderly.

The Claims Specialist will support 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.

The ideal candidate will have coding/claims experience, data analysis a plus.

• Location: Bronx
• Pay Rate: $27
• Schedule: Monday-Friday 8:30 am-5:30 pm (1 hour lunch) (FT), Hybrid Wednesday and Friday in the office.
• Weekly Hours: 40

JOB 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, (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

• 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:

Education: Bachelor's degree. Certified Professional Coder (a plus)

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
• 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

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