Claims Research Specialist
Claims Research Specialist
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Salary Not Disclosed
1 Vacancy
Job Description
Overview
Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.
Responsibilities
The Claims Research Specialist will oversee and manage research efforts related to claims overpayments underpayments and billing issues within a managed care service organization. This role involves review/ensuring accurate and timely resolution of discrepancies and working collaboratively with providers and internal departments to enhance claims processes and improve financial outcomes.
Essential Functions:
- To research and identify root cause resulting in claim processing discrepancies for all claim types
- Perform an analysis of the claims processing by reviewing contract system configuration benefits financial risk (DOFRs) and manual adjudication to identify the cause of the erroneous claim payment
- Responsible to ask clarifying questions from our internal supporting departments or external providers when information is incomplete or inaccurate to ensure thorough and accurate research
- Responsible for communicating via inquiry form email and telecommunication across multiple areas of the organization to ensure customer resolution is complete
- Lead investigations into claims overpayments underpayments and billing issues ensuring accurate identification and resolution of discrepancies.
- Analyze complex claims data to identify trends root causes and opportunities for process improvement.
- Ensure thorough documentation of all research activities and findings maintaining accurate records for audit purposes.
- Collaborate with internal departments including claims processing UM compliance and provider relations to develop and implement strategies to prevent future claims issues.
- Participate in the development and enhancement of claims processing systems and tools.
- Recommend policy and procedure changes based on research findings to improve efficiency and accuracy in claims processing.
- Serve as the primary point of contact for the providers and/or provider relations team regarding claims research issues facilitating effective communication and resolution of disputes.
- Educate providers on claims submission guidelines and billing practices to reduce the occurrence of errors.
- Build and maintain strong working relationships with provider representatives.
- Prepare and present detailed reports on claims research activities findings and outcomes to senior management.
- Ensure compliance with all relevant federal state and local regulations as well as organizational policies and procedures.
- Monitor and respond to regulatory changes that impact claims processing and research activities.
- Schedule and lead meetings with all affected areas to provide status updates of next steps expected completion dates and resolution of the issues
- Maintain and monitor a comprehensive dashboard of the current open and resolved claim issues
Qualifications
Minimum Qualifications:
- Bachelors degree in Business Healthcare Administration or a related field or experience in lieu of.
- Minimum of 5 years of experience in claims research analysis or a related role within a managed care or healthcare environment
- Proven experience in a lead role with strong project team management skills.
- Advanced knowledge of healthcare claims processing coding (ICD-10 CPT HCPCS) and billing practices.
- Proficiency in using a managed care and/or claims processing platform.
Preferred Qualifications:
- Experience with data analytics tools and software such as SQL SAS
- Previous experience working directly with healthcare providers or within a provider network setting
- Masters in Business Healthcare Administration or related field
Required Experience:
Unclear Seniority
Employment Type
Unclear
