Description
Claims Consultant
Position Requirements/Responsibilities:
- 5-7 years experience with ePremis/Healthcare Claims application and has extensive knowledge of edits by Line of Business.
- Significant knowledge (usually 5-7 years) of medical coding, billing systems, techniques, and procedures and demonstrated ability to analyze the systems and procedures for the purpose of improving accuracy, completeness, revenue optimization, encouraging compliance and best practices.
- Certified HFMA, preferable.
- Assists with the coordination of basic user administration (ie access - adds, changes, deletes).
- Maintains and enforces change management process - manages service requests from business.
- Implement changes. Maintain system configuration and documentation of system configuration.
- Perform testing of changes and co-ordinate with business to provide approval for TEST and PROD migration
- Performs related duties as assigned or requested.
- Develops technical expertise in ePremis claims application.
- Determines training needs of end users.
- Acts as liaison with outside vendors.
- Coordinates all changes to the application and technical environment
- Performs testing and validation
- Researches potential improvements
- Traces potential issues from host system generation
- Obtains business requirements for all change requests (SRs)
- Creates and submits SRs to ePremis
- Monitors and tracks all SRs
- Performs testing and validation of all SRs
- Determines business/training impacts
- Coordinates work with all IT groups, as necessary
- Works with operations to determine root cause of claims errors
- Works with operational groups and ePremis to determine end-to-end solution design
- Performs UAT validations during system outages and upgrades
- Coordinates claim release suspension in conjunction with legal holidays
- Create Business Requirements Document (BRD)
- Ensures there is no reporting impact associated with system changes
- Initiates ePremis application Key Messages and System notifications
- Initiates request for Edit Disputes. Open SR to ePremis IT. ePremis IT opens Service Order (SO) to Relay Health.
- Approves all application configuration changes
- Application SME for National & Regional projects and initiatives
- Performs UAT validations during system outages and upgrades
- Coordinates claim release suspension in conjunction with legal holidays
- Works with operations to determine root cause of claim errors
- Works with operations, PFS and ePremis to determine end-to-end solution design
Identifies new Provider Specialties that need to be updated in the Physician Master via Ab Initio - Monitors Master File errors to decrease error rate
- Deletes claims when appropriate to avoid duplicates
- Generates Unreleased Deleted Claims Report whenever claims are deleted in the application
- Validates and reconciles claim runs from CLIENTHC to ePremis. Accepts/rejects CLIENTHC claim runs in CLIENTHC
- Identifies and submits missing claims, as necessary
- Monitors and reconciles claims holding in ePremis, such as claim errors or system enhancements/changes
- Coordinates remediation work with CLIENTHC, ePremis IT, Operations and PFS to remediate claims reconciliation issues
- Partners with PFS supervisors to remediate Discarded claims
- Provides discrepancy analysis for 07.07.06 Monthly SOX control audit
- Responsible for saved documentation supporting claims acceptance process
- Resolves discrepancies found during the bridging process
- Works with operations to determine root causes and designs potential technical solutions
- Creates change requests (SRs), as needed Incident tracking database until resolution
- Reassigns incidents not related to the ePremis application to the appropriate group after researching (ie, Resolute IT) Drive business requirements gathering
- Ensures end-to-end data integrity and quality-coordinates work with ePremis, operations and PFS
- Works with operations to research data gaps and data issues
- Creates change requests (SRs), as needed
- Ensure EDI enrollment Questionnaire is completed and submitted PFS OI
- Obtains business requirements for all change requests (SRs)
- Creates and submits SRs to ePremis
- Performs testing and validation of claims with CLIENTHC and ePremis IT
- Determines business/training impacts