Description
Position type: w2
Contact duration: 13+ months (strong possibility of extension)
Experience Requirements
3 years’ experience in health insurance or managed care environment
3 years’ experience in claims processing/resolution
2 years of the any of following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules
Top three skills
Proficiency in medical terminology, medical coding (CPT4, ICD9/, and HCPCS), provider contract concepts and common claims processing/resolution practices
Strong experience in documentation, research and reporting
Strong analytical and problem solving skills
Top 5 daily responsibilities
Ensures the provider, authorization and benefits configuration meets established business rules and procedures
Loads new contracts/authorization/benefit configuration into Xcelys
Performs problem resolution of configuration issues
Consults with relevant contract manager or business analyst to determine appropriate interpretation and configuration of contract terms
Develops, documents and executes test plans for configuration testing and validate accuracy of data loaded
Top 3 Personality Characteristics: Analytical, team player, self-driven
• Performs Configuration Activities (which may include at least one of the following: Institutional and Provider Contracts, Benefits Authorizations, and/or General Configuration such as System Edit Rules, Fee Schedules updates, etc.) in Diamond Claims Processing system resulting in 100% claim payments consistent with the contractual arrangement(s) made with the Provider, and according to the Groups Evidence of Coverage (EOC)
• Ensures the provider, authorization and benefits configuration meets established business rules and procedures.
• Modifies the provider contract, authorization rules and benefit plan configuration as required.
• Loads new contracts/authorization/benefit configuration into Diamond.
• Uses MACESS workflow to monitor contract updates and contract(s) matrix/grid.
• Performs problem resolution of configuration issues.
• Consults with relevant Contract Manger or business analyst to determine appropriate interpretation and configuration of contract terms.
• Maintains detailed knowledge and understanding of Diamond rules relative to claims payment.
• Analyzes provider contracts to determine the best approach for loading data elements into the claim processing system
• Analyzes benefit explanation of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums and state/regulatory benefits
• Analyzes medical management requirement to determine best approach for loading authorization rules into the claims processing system
• Develops, documents and executes test plans for configuration testing and validate accuracy of data loaded
• Performs problem resolution of configuration issues and documents results for the repository
• Coordinates research and resolution of debarred and sanctioned providers and ensures communication of required system updates to Provider Contracting and Claims Operations
• Conducts research and resolution of claim match rules and authorization rules and communicates required system updates to Medical Management