Neighborhood Health Plan of Rhode Island
Senior Claims Adjuster
Neighborhood Health Plan of Rhode Island, Smithfield, Rhode Island, us, 02917
Job Details
Job Location
Smithfield, RI - Smithfield, RI
Position Type
Full Time
Education Level
High School or GED
Travel Percentage
None
Job Shift
Daytime
Job Category
Some Experience
Description
The Senior Claim Adjuster is responsible for assisting in the day to day managing of claim issues for high profile providers. This role acts as the single point of contact for their assigned accounts for any claim related issue. They are the liaison/advocate between the provider and internal departments. The Senior Claim Adjuster works directly with practice managers, via phone, email and in-person meetings on a regular basis to resolve outstanding claim issues. This role works with our Provider Contracting and Provider Relations departments to assist in managing the operational aspects of the provider relationship, and will attend internal meetings to present their research and findings on claims issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming inquiries regarding current claims and escalated issues. Collaborates in strategic planning for their assigned accounts. Works collaboratively with business and operational units to ensure prompt resolution of open issues. . They assume ownership and accountability for the timely and accurate identification and resolution of claims issues through thorough research using the necessary tools such as a review of provider contracts, benefits, JIRA tickets, CES edits, NCCI edits, correct coding, reporting, testing, and other appropriate tools.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
Serves as the SME and Lead on functional deliverables ensuring optimal efficiency in all areas of responsibility
Tracks and maintains all known issues, including the operational provider issue logs, and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
Conducts extensive research on complex payment inaccuracies and documents root cause analysis and mitigation
Receives and responds timely to correspondence on escalated issues
Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system.
Request appropriate adjustment via AWD to the Claims BPO
Represents Neighborhood to internal and external customers in a professional manner
Attends ad-hoc and regularly scheduled operational meetings with provider community within and outside of the organization
Responsible for documenting deliverables from meetings/calls and providing timely resolution of same.
Collaborates with other departments to root cause and resolve claim payment issues. Opens JIRA tickets as needed.
Provides support and guidance to all Claims teams on identified system issues
Partners with the Documentation Specialist to create desktop procedures
Supports testing of new functions, features, system upgrades and new implementations
Other duties/special projects as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required
:
Associates degree or equivalent relevant work experience in lieu of a degree
Minimum of five (5) years experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)
One (1) or more years experience working in direct relation with the provider community (claim resolution, GAU, provider relations, contracting, etc.)
Strong understanding and experience in all aspects of claims adjudication, processing, and analysis.
Ability to manage multiple projects simultaneously
Demonstrated experience with managing and cultivating strong business relationships with the provider community
Ability to understand business systems and articulate deficiencies and opportunities
Understanding of provider reimbursement mechanisms
Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
Basic understanding of contract implementation and working knowledge of contract language
Must exercise excellent judgment and be effective working autonomously and as part of a team
Exceptional listening skills and verbal/written communication skills
Problem solver with strong attention to detail
Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors.(internal candidate)
Must be knowledgeable of resources available within the organization to resolve both internal and external problems and concerns.
Strong information management skills including the ability to organize information, identify subtle and/or complex service delivery issues that impact customers and the ability to articulate and pursue solutions to problems impacting service
Knowledge of HIPAA standards and CMS guidelines
Preferred
:
Bachelors degree
Coding Certification from the American Academy of Professional Coder (AAPC) or American Health Information Management Association (AHIMA)
Prior experience with JIRA issue tracking system or a similar project tracking system
Experience with Optum Encoder or similar coding program/website
Prior Network Management experience
Project Management experience
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Build Relationships & Cultivate Networks
Attend to Detail & Improve Quality
Exercise Sound Judgement & Decision Making
FDR Oversight:
N/A
Flexible Work Arrangement:
Yes
Telecommuting Arrangement:
No
Travel Expectations:
N/A
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
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Job Location
Smithfield, RI - Smithfield, RI
Position Type
Full Time
Education Level
High School or GED
Travel Percentage
None
Job Shift
Daytime
Job Category
Some Experience
Description
The Senior Claim Adjuster is responsible for assisting in the day to day managing of claim issues for high profile providers. This role acts as the single point of contact for their assigned accounts for any claim related issue. They are the liaison/advocate between the provider and internal departments. The Senior Claim Adjuster works directly with practice managers, via phone, email and in-person meetings on a regular basis to resolve outstanding claim issues. This role works with our Provider Contracting and Provider Relations departments to assist in managing the operational aspects of the provider relationship, and will attend internal meetings to present their research and findings on claims issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming inquiries regarding current claims and escalated issues. Collaborates in strategic planning for their assigned accounts. Works collaboratively with business and operational units to ensure prompt resolution of open issues. . They assume ownership and accountability for the timely and accurate identification and resolution of claims issues through thorough research using the necessary tools such as a review of provider contracts, benefits, JIRA tickets, CES edits, NCCI edits, correct coding, reporting, testing, and other appropriate tools.
Duties and Responsibilities:
Responsibilities include, but are not limited to:
Serves as the SME and Lead on functional deliverables ensuring optimal efficiency in all areas of responsibility
Tracks and maintains all known issues, including the operational provider issue logs, and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
Conducts extensive research on complex payment inaccuracies and documents root cause analysis and mitigation
Receives and responds timely to correspondence on escalated issues
Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system.
Request appropriate adjustment via AWD to the Claims BPO
Represents Neighborhood to internal and external customers in a professional manner
Attends ad-hoc and regularly scheduled operational meetings with provider community within and outside of the organization
Responsible for documenting deliverables from meetings/calls and providing timely resolution of same.
Collaborates with other departments to root cause and resolve claim payment issues. Opens JIRA tickets as needed.
Provides support and guidance to all Claims teams on identified system issues
Partners with the Documentation Specialist to create desktop procedures
Supports testing of new functions, features, system upgrades and new implementations
Other duties/special projects as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications
Qualifications
Required
:
Associates degree or equivalent relevant work experience in lieu of a degree
Minimum of five (5) years experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)
One (1) or more years experience working in direct relation with the provider community (claim resolution, GAU, provider relations, contracting, etc.)
Strong understanding and experience in all aspects of claims adjudication, processing, and analysis.
Ability to manage multiple projects simultaneously
Demonstrated experience with managing and cultivating strong business relationships with the provider community
Ability to understand business systems and articulate deficiencies and opportunities
Understanding of provider reimbursement mechanisms
Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
Basic understanding of contract implementation and working knowledge of contract language
Must exercise excellent judgment and be effective working autonomously and as part of a team
Exceptional listening skills and verbal/written communication skills
Problem solver with strong attention to detail
Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors.(internal candidate)
Must be knowledgeable of resources available within the organization to resolve both internal and external problems and concerns.
Strong information management skills including the ability to organize information, identify subtle and/or complex service delivery issues that impact customers and the ability to articulate and pursue solutions to problems impacting service
Knowledge of HIPAA standards and CMS guidelines
Preferred
:
Bachelors degree
Coding Certification from the American Academy of Professional Coder (AAPC) or American Health Information Management Association (AHIMA)
Prior experience with JIRA issue tracking system or a similar project tracking system
Experience with Optum Encoder or similar coding program/website
Prior Network Management experience
Project Management experience
Core Company-Wide Competencies:
Communicate Effectively
Respect Others & Value Diversity
Analyze Issues & Solve Problems
Drive for Customer Success
Manage Performance, Productivity & Results
Develop Flexibility & Achieve Change
Job Specific Competencies:
Collaborate & Foster Teamwork
Build Relationships & Cultivate Networks
Attend to Detail & Improve Quality
Exercise Sound Judgement & Decision Making
FDR Oversight:
N/A
Flexible Work Arrangement:
Yes
Telecommuting Arrangement:
No
Travel Expectations:
N/A
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
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