NCP Claim Appeals Specialist
NCP Claim Appeals Specialist
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Job Description
Alignment Health is breaking the mold in conventional health care committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fastgrowing company you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters not only changing lives but saving them. Together.
The Provider Dispute Resolution Specialist (Specialist) is responsible for processing provider appealsand disputes accurately and timely. The Specialist assesses and completes appropriate documentation
for tracking/trending data. Conducts all pertinent research in order to respond and process incoming
provider appeals and disputes in accordance with all established CMS Medicare Advantage regulatory
contractual and departmental guidelines. The Specialist processes the claim(s) accordingly within the
claim system while following department processes. Interface with internal departments and external
resources and organizations. Prepares and assist with departmental reports as needed.
GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO):
Properly distinguishes between a provider dispute and a provider appeal. Confirm each provider appeals are correctly identified for appropriate tracking and reporting
Updates tracking system to ensure cases are processed timely and appropriate actions are taken
Reviews and processes provider appeal and dispute determinations according to CMS contractual and processing guidelines. Issue appropriate documentation and payments accurately and timely.
Corresponds with delegated entity as needed to obtain appropriate records or payment information
Prepares appropriate documentation and submit to IRE when provider appeals result in adverse determination and/or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.
Processes/Adjudicates claim(s) according to departmental procedures
Meets and consistently maintains quality and productivity standards as defined by the Management.
Identifies denial or payment variance trends and escalates to department management as appropriate for training opportunities and corrective action.
Assists in preparing and reviewing cases for regulatory and other health plan audits
Actively participates in ongoing training to support company and department initiatives. Supports department initiatives in improving processes and workflow efficiencies
Adheres to all regulatory and company standards as described in the Employee Handbook and departmental Policies and Procedures. Complies with companys time and attendance policy.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
Foster good corporate relations by practicing good customer service principles (i.e. positive attitude helpful etc.) and teamwork.
Performs additional related duties as assigned by Management
SUPERVISORY RESPONSIBILITIES: N/A
MINIMUM REQUIREMENTS: To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Minimum Experience:
a. 3 years experience processing Medicare Advantage provider appeals from all types of providers (hospitals physicians ancillary)
b. 3 years experience in examining all types of medical claims preferably Medicare Advantage claims
2. Education/Licensure:
a. High School Diploma required
b. Bachelors Degree in related field preferred
3. Specialized Skills:
a. Effective interpersonal skills to consistently demonstrate expertise business knowledge team cohesiveness respect nonalarming directives and patience while interacting during system outages and critical deadlines.
b. Excellent communication skills especially in oneonone and smalllarge group settings are essential.
c. Working knowledge of claims processing systems (EZCAP preferred)
d. Working knowledge of medical terminology standard coding and reference publications CPT HCPC ICD9 ICD10 DRG etc.
e. Understanding of different payment methodology such as Medicare PPS (MSDRG APC etc.) Medicare Physicians fee schedule Per Diem etc.
f. Understanding of Division of Financial Responsibility on how they apply to claims processing
g. Familiarity with billing and coding edits coordination of benefits MA Organization Determination Appeals and Grievance procedures
h. Proven problemsolving skills and ability to translate knowledge to the department.
i. Working knowledge of Microsoft Office Programs (Outlook Excel and Word)
j. Excellent verbal and written communication skills
k. Strong Organizational Skill and ability to multitask
l. Attention to Detail
m. Ability to use 10 keys
ESSENTIAL PHYSICAL FUNCTIONS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job the employee is regularly required to talk or hear. The employee regularly is required to stand walk sit use hand to finger handle or feel objects tools or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability age protected veteran status gender identity or sexual orientation.
*DISCLAIMER:Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employmentrelated offers in exchange for money or other sensitive personal be advised that Alignment Health and its subsidiaries will never ask you for a credit card send you a check or ask you for any type of payment as part of consideration for employment with our you feel that you have been the victim of a scam such as this please report the incident to the Federal Trade Commission at If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Healths talent acquisition team please email.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
