Job DescriptionThis position serves as point of contact and subject matter expert for research and remediation of system and claim issues working with other departments as required to complete standard and adhoc financial impact analysis. This position is responsible for monitoring regulatory changes related to claims payment or administration and researches and analyzes projects and correspondences. Identify systems, configuration and processing problems, errors and trends. Responsible for communicating any changes needed to appropriate stakeholders and assisting with implementation of these changes. Role is responsible for claims research and for oversight audits to ensure processed claims are in compliance with departmental policies, procedures, government guidance, and claims financial liabilities.
- Reviews adjudicated claims to determine appropriate levels of completeness, accuracy and timeliness are met.
- Functions as technical specialist for claims adjustment operations. Analyze complex operational claim payment problems and provide technical data. Identify and recommend claims that should and should not be adjusted. Provide support to various staff.
- Responds to and resolve claim adjustment inquiries. Provide documentation, as appropriate, to support claim adjustment resolution.
- Maintains a current working knowledge of processing rules, contractual guidelines, plan policies and operational procedures to effectively provide technical expertise.
- Identifies process gaps and trends; then provide explanations and feedback to staff and management.
- Identifies key issues with projects and offer solutions.
- Provides technical and peer in-service training.
- Conducts cross training and act as mentor to staff as required. Serve as a subject matter expert as needed.
- Audits claims from various sources.
- Reports on accuracy in the areas of adjustment errors.
- Re-processes claims as needed.
- Performs validation of claims from an overall perspective, including the validity of the data entry process, the analyst’s adjudication process, the investigative process, and the validity of the enrollment process.
- Identifies claims that appear suspicious to management for further investigation.
- Monitors work processes and confirm that they are in agreement with policies and procedures.
- Answers claims adjudication and/or system questions.
- Serves as a resource regarding claims processing procedures.
General Job Information
TitleAdjustments - Claims Research Analyst (REMOTE)
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date7/15/2019
Date Requisition Created7/3/2019
Work ExperienceClaims, Healthcare, Pharmacy
EducationA Combination of Education and Work Experience May Be Considered. (Required), Bachelors (Required)
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
- Minimum 5 years of healthcare claims and reimbursement experience.
- Ability to learn and implement new processes and procedures quickly.
- Ability to work both independently and as part of a team.
- Detail oriented.
- Health Plan, PBM or Pharmacy claims experience.
- In-depth knowledge of claims payment methodology.
- Knowledge of health care claim adjudication procedures and standards.
- Knowledge of health care industry.
- Organized with strong time management skills.
- Previous claims auditing experience.
- Strong analytical skills.
- Strong working knowledge Microsoft Office Product Suite. Willing and able to quickly learn new software applications.
- Strong written and verbal communication skills.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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