Medical Claims Examiner

Medical Record Unit Examiner I/II/III (Claims) (Finance) Job Description: Summary: Responsible for managing and providing divisional support to all Medical Records Unit (MRU) activities such as medical record requests, receipts, research and tracking through the medical record database. Research Facets, Plan Connexion processing system and control workflow to ensure intakes are handled timely by the appropriate area, including BlueCard and Local claims, to ensure performance metrics are met. Essential Accountabilities: Level I Responsible for the quality assurance of all internal and external medical record requests and the determination of appropriate outgoing communication. Review medical record receipts including unsolicited medical records for completeness and determine appropriate workflow. Interface with and extract data from the Facets and/or Plan Connexion processing systems to prepare and complete medical record reports. Process and maintain current and accurate Department of Labor medical record requests. Assist Claim Examiners with questions. Initiate and participate in learning opportunities around regulations, systems, procedures and skills needed for the role. Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) Efficiently resolve escalated organizational requests and inquiries. Identify trends, determine root cause and recommend potential solution. Research, track and resolve Department of Labor medical record requests for Home plan including Plan Connexion. Resolve all types of medical record review transactions which includes Host and Local claims. Observe fluctuations in inventory levels and elevate to Level III for investigation. Train Level I employees on department processes/functions. Level III (in addition to Level II Accountabilities) Resolve medical record review transactions which includes Host, Home and Local claims. Identify trends, determine root cause, communicate risk to leadership and initiate action for resolution. Mentor and train on lines of business within MRU. Support analytical work. Serve as subject matter expert testing new system implementations and improvements. Identify, recommend and initiate process as well as desk level documentation improvements. Provide productional support to areas outside of MRU based on business need. Participate as subject matter expert in project and process improvement related work for MRU. Responsible for maintenance of the Medical Record Database. Monitoring inventory fluctuations within workstreams to coordinate, delegate and execute inventory control/assignment plan. Coordinate invoicing for payment of medical records. Learn and support areas outside of MRU. Provide resolution of complex and escalated issues. Minimum Qualifications: NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels High school diploma or equivalent required. Office experience and claims background preferred. Basic computer skills required including the ability to navigate in a Windows environment. Able to work between multiple programs and applications at the same time. Strong self-management skills including but not limited to reasoning, problem-solving, change management, communication, time management and organizational skills. Ability to meet minimum performance metrics. Ability to arrive on time at work and as scheduled. Level II (in addition to Level I Qualifications) Ability to analyst data and identify trends. Ability to mentor and train. Exceed performance expectations for a minimum of one (1) year and/or meet performance expectations for three (3) years as a Level I. Level III (in addition to Level I Qualifications) Demonstrated in-depth knowledge of, and ability to coach/support MRU on all lines of business and other areas within Claims. Exceed performance expectations for a minimum of three (3) years and/or meet performance expectations for five (5) years. Physical Requirements: The ability to hear, understand, and speak clearly while using a phone, with or without a headset. Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time. Ability to travel across the Health Plan service region for meetings and/or trainings as needed. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. 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 status as a protected veteran. Compensation Range(s): Level I: Grade N2: Minimum: $20.00 - Maximum: $24.43 Level II: Grade: N3: Minimum: $20.40 - Maximum: $27.00 Level III: Grade: N4: Minimum: $20.80 - Maximum: $30.80 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays. Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis. #J-18808-Ljbffr