Location: El Paso TX
Company Name: Superior HealthPlan
Occupational Category: 21-1093.00,Social and Human Service Assistants
Date Posted: 2020-03-18
Valid Through: 2020-04-17
Employment Type: FULL_TIME
Position Purpose: Review high dollar claims for appropriate place of service, length of stay, match to authorization, and possible outlier DRG or Stop Loss pricing. Conduct complex business and operational analyses to assure payments are in compliance with contract; identify areas for improvement and clarification for better operational efficiency.
• Work collaboratively with various cross-functional departments to determine appropriateness of pricing
• Work collaboratively with Medical Management Department to resolve any issues with medical review notes that affect high dollar claim pricing
• Serve as a technical resource / coding subject matter expert for contract pricing related issues
• Responsible for entire cycle of high dollar claims which includes verifying information on submitted claims, reviewing contracts, compliance guidelines, state regulations, eligibility, and authorizations to determine reimbursement, and releasing claim for payment
• Identify key elements and processing requirements based on diagnosis, provider, contracts and policies and procedures utilizing broad based product or system knowledge to ensure timely payments are generated.
• Conduct point of service review and resolution of high dollar claims that are pending and/or adjusted incorrectly including review, investigation, adjustment and resolution of claims, claims appeals, inquiries, and inaccuracies in payment of claims.
• Collaborate with all departments to analyze complex claims issues and special claim projects which are identified through high dollar review
• Review inventories to determine appropriate task to complete first and key performance indicators are met
• Manage and provide testing on new product or system configuration to determine success rate of such product or configuration prior to go-live