Description:
This role will be located within the payment integrity department and work collaboratively with team members and department/ enterprise associates who support efforts to identify aberrant provider billing.
A Day In The Life
- Administers client specific contract benefits.
- Translate narrative descriptions into proper code.
- Research and resolve complex system edits.
- Ensure timely and accurate payment or denial of adjustments by monitoring reporting and following through with leadership or Claim Processors.
- Document any additional information or specific action taken using the proper system.
- Identify contract specific situations and manually calculate contract benefits using pricing and out-of-pocket procedures.
- Research and process or adjust high dollar claims.
- Analyze complex requests to determine how the original claim processed.
- Determine outcome of a reprocessed claim before the claim finalized. Identify and recommend areas for process improvement.
- Complete assigned special projects that require research, analysis and documentation.
- Serve on committees and task teams related to claims or adjustment efficiencies and methodologies.
- Provide on-the-job training and mentoring to Claim Processors and Associate Claim Processors.
- Research and respond to complex written correspondence via phone or in writing.
Nice To Have
- Ability to take direction and to navigate through multiple systems simultaneously.
- Knowledge of administrative and clerical procedures and systems such as Excel in order to manage workload.
- Ability to use mathematics to adjudicate claims.
- Ability to solve problems within pre-defined methods and guidelines.
- Knowledge of operating systems specific to claim processing.
- Oscar claim adjustment experience.