JOB SUMMARY
This job ensures that services provided to health plan members and billed by providers to the health plan are submitted to respective State agencies and CMS accurately and timely. Ensures accuracy of complex data with minimal errors to further ensure that health plan medical expense on file at respective State and CMS is complete and up to date.Completes complex root cause analysis and research of errors to generate corrections in a timely manner to provide an accurate picture of medical expense and avoid penalties from the State and/or CMS. Provides guidance and education to lower level employees.
This is a remote based role however will need to go onsite 1 day a month.
ESSENTIAL RESPONSIBILITIES
- Actively participate in decision making process and documentation for meeting Service Level Agreements (SLA) set by respective states of operation
- Lead regular meetings with Internal and External Clients/Vendors to review projects globally, coordinate collaborative efforts and knowledge sharing among all team members, seeking opportunities to leverage existing processes.
- Analyze and research complex encounter errors to identify root cause(s) and make recommendations for resolution.
- Research and document all encounter errors in established database(s).
- Communicate regularly with management on issues discovered through research efforts.
- Communicate with and provide clear, detailed, effective documentation to other departments within the organization on issues causing encounter pends/denials and potential solutions.
- Handle reversals / recoupments resulting from encounter errors.
- Produce monthly summary reports identifying adjudication errors.
- Other duties as assigned or requested.
EDUCATION
Required
Substitutions
Preferred
- Bachelor’s in healthcare analytics or related field
EXPERIENCE
Required
- 5 - 7 years in Encounters, Claims Processing or Claims Billing
Preferred
LICENSES AND CERTIFICATIONS
Required
Preferred
SKILLS
- Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Demonstrated organizational skills
- Ability to work independently
- Ability to work as part of a team
- Ability to work in a fast paced environment with changing priorities
- Demonstrated written communication skills
- Demonstrated interpersonal/verbal communication skills
- Demonstrated research skills
- Demonstrated detail orientation
- Understanding of AHCCCS and CMS rules/regulations including encounter process
- Health/Medical Programs
- HIPAA
- Outlook
- Microsoft Office
- Microsoft Excel
Language (Other than English)
None
Travel Required
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Frequently
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
