CLAIMS SPECIALIST
Location :
Wallerstein, NY
Job Type :
Temp/Contract
Reference Code :
Wallerstein
Job Industry :
Healthcare - Health Services
Job Description :
Cross Country Workforce Solutions Group is looking for a Claims Specialist in Wallerstein, NY.
Claims Specialist
Location: Wallerstein, NY
Setting: Hybrid (2 days onsite typically Wed & Fri - remaining days work remotely)
Pay: $25 Per Hour
Schedule: Monday - Friday, 9am-5pm
Assignment Length: Temp with possibility of conversion.
JOB RESPONSIBILITIES
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
- Additional duties as assigned.
Required Qualifications :
QUALIFICATIONS:
Education: Bachelor's degree.
Certified Professional Coder (a plus)
Experience:
Claims adjudication experience
Knowledge of MLTC/ Medicaid/Medicaid benefit
Knowledge of Member (Subscriber) enrollment & billing
Knowledge of Utilization Authorizations
Knowledge of Provider Contracting
Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS
Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software
Eight or more years of insurance experience within a healthcare or managed care setting (preferred)
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