Claims Associate; Asheville, NC

LOCATION: Asheville NC - this is an in person, office-based position that operates Monday - Friday from 8:30am-5:00pm EST. The person in this position should live within a reasonable commute to Vaya's Asheville office.

GENERAL STATEMENT OF JOB

Responsible for all accounting functions related to a designated area of physical and behavioral health medical claims processing to ensure that providers receive timely and accurate payment. This position is responsible for managing paper claims. This incumbent will ensure valid paper claims are loaded to the claims adjudication system timely, as well as manage communication back to provider for claims that are unable to be accepted in the system due to missing or invalid claims data.

This role will support claims adjudication efforts through continuous monitoring and quality control measures.

ESSENTIAL JOB FUNCTIONS

The Claims Representative II is responsible for (though not limited to):

• Paper claims
  • Keying of valid paper claims to claims adjudication system
  • Manage invalid claims - return mail to provider
• Rejections
  • Processing of rejections out of Perfect Claims
  • Return mail or email rejection letters to provider
• Reconsideration Letters
  • Reconsideration letters to be sent regarding Claim appeals received by Vaya.
• Customer Service support
• Support claims adjudication by finalizing claims processed electronically for payment and reviewing claim adjudication results for both Title XIX and non-title XIX claims, payment, and denial patterns
• Ensure adjudication accuracy of keyed claims in the claims processing system by adhering to policy and procedures.

Paper Claim: This position will be responsible for tracking all paper claims. This position will evaluate claims to determine Clean claim vs. Non-clean claim. Clean claims will be loaded to the claim system for adjudication. Non-clean claims will be returned to providers. This position will ensure all mailroom activities are completed within service level agreement timeliness.

Claims Adjudication: This position will be responsible for finalizing keyed claims processed for payment and maintain claims adjudication workflow, reconciliation and quality control measures to meet or exceed prompt payment guidelines. This position is responsible for reconciling provider claims payments through quality control measures, generally accepted accounting principles and Vaya's policies and procedures. This position will assess Title XIX and non-Title XIX claims adjustments for correction or recoupment and will coordinate the recoupment process to ensure payment is recovered for inappropriately paid claims.

Customer Service: This position will maintain provider satisfaction by being available during regular business hours to handle inquiries; interacting in a professional manner; and providing information and assistance. This position will also answer incoming calls as needed. This position will assist providers in resolving problem claims and system training issues. This position will also serve as a resource for internal staff to resolve eligibility issues, authorization, over payments, recoupment or other provider issues related to claims payment.

Compliance and Quality Assurance: This position reviews internal bulletins, forms, appropriate manuals and applicable revisions, and fee schedules to ensure compliance with established procedures and processes. Attend and participate in workshops and training sessions to improve technical competence.

Miscellaneous: Other duties as assigned, including coverage of specific functions of other staff to assist the Department as work demands may dictate.

KNOWLEDGE, SKILLS, & ABILITIES

• Knowledge of computerized claims systems; organization structure of MCO claims processing, methods and procedures utilized in claims processing, medical terminology (ICD-10/CPT/HCPCS and Revenue codes), third-party reimbursement, and Coordination of benefits (COB).
• Ability to adapt to a rapidly evolving work environment, work independently, and communicate with a variety of personnel and providers.
• Ability to process moderate to more complex claim issues.
• Knowledge of all types of health insurers and coordination of benefits…