Claims Research Specialist (39887)

The Claims Research Specialist is responsible for the day to day handling of claim issues. This role acts as the single point of contact for claim related issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming inquiries regarding escalated claims issues. Collaborates in strategic planning, 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:

• Acts as a subject matter expert (SME) and resource/support for internal departments and management on issues involving Claims and Benefits

• Identifies issue and inquiry patterns and trends impacting performance and communicates concerns to management

• Conducts in-depth research on complex claim issue requests received through internal processes

• Reviews claims errors to determine a system or manual error, or educational opportunity internally

• Document research outcomes and adjusts claim(s) per benefit policies and procedures, if necessary

• Follow up with appropriate individuals or areas to gather additional information to remedy issues

• Clearly document sources and validate the accuracy of data/information to resolve inconsistencies

• Tracks and maintains all known claim issues

• Identify work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction

• Identify process improvements to effectuate streamlined processes, minimizing or negating issues

• Documents root cause analysis and mitigation

• Receives and responds timely to correspondence on escalated issues

• 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 within the organization

• Responsible for documenting deliverables from chaired meetings, tracking progress and providing timely status updates to progress

• Collaborates with other departments to identify and document root cause to resolve claim payment issues. Opens JIRA tickets as needed

• Provides support and guidance to all Claims teams on identified system issues

• Partners with the Claims Documentation Coordinator to create desktop procedures

• Supports testing of new functions, features, system upgrades and new implementations

• Performs other duties/special projects as assigned

• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's 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:

• Bachelors degree or equivalent relevant work experience and education 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

• Ability to understand business systems and articulate deficiencies and opportunities in both claim processing systems; HealthRules and Amisys.

• Understanding of provider reimbursement mechanisms

• Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)

• 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.

• Must be able to collaborate with business Areas throughout NHPRI to insure resolution(s)

• Must have strong information management skills including the ability to organize information, identify subtle and/or complex issues that impact customers.

• Must have the ability to articulate and pursue solutions with various Business area's to insure problem resolution of impacted service

• Knowledge and Understanding of HIPAA standards, CMS guidelines, EDI, UB04 and CMS 1500 data elements as well as NUBC requirements.

• Ability to partner on issue identification and resolution with outsourced entities.

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

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.