"Alerted.org

**Req Number** 158358

FlexStaff is seeking a Temp to Perm 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

*Additional Salary Detail

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

The salary range for this position is $27-$27/hour

It is Northwell Health’s policy to provide equal employment opportunity and treat all applicants and employees equally regardless of age, race, creed/religion, color, national origin, immigration status, or citizenship status, military or veteran status, sexual orientation, sex/gender, gender identity, gender expression, height, weight, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, their or their dependent’s sexual or other reproductive health decisions, or other characteristics protected by applicable law.