Medical Claims Specialist

Job Description The Claims Specialist will be responsible for reviewing claims processed by the outside vendor, including resolving provider appeals/disputes. Performs root cause analysis for all provider projects to identify areas for provider education and/or system (re)configuration. Initiates and follows through with resolution of all pended claims, (re)pricing, returned or refund checks and the development of provider and facility compensation grids. Provides feedback or suggestions to enhance current processes or systems. Reviews and investigates claims to be adjudicated by the TPA, including the application of contractual provisions in accordance with provider contracts and authorizations Compiles claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner Investigates suspense conditions to determine if the system or procedural changes would enhance claim workflow Communicates and follows up with a variety of internal and external sources, including but not limited to providers, members, attorneys, regulatory agencies, and other carriers on any claim related matters Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor Attends JOC meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines Assists TPA with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processing Ensures that refund checks are logged and processed, enabling expedited credit of monies returned Analyzes check return/refunds volumes and trends to determine root causes. Proposes workflow changes to correct and enhance claim processes to prevent returned checks/refunds Generates routine daily, monthly and quarterly reports used for managing process timeframes and vendor productivity, ensuring compliance with all regulatory requirements and contractual vendor SLAs Participates in special projects and performs other duties as assigned #J-18808-Ljbffr