Policy and Claims Research Specialist

Overview

The Policy and Claims Research Specialist is responsible for supporting the Payment Integrity initiatives and projects. This role will act as the point of contact for claim related research. Serves as a claims subject matter expert (SME) and handles inquiries regarding Payment Integrity projects related to claims issues, policies and CES edits. Collaborates in planning, and works closely with business and operational units to ensure timely resolution of open issues.

The Specialist assumes ownership and accountability for the timely and accurate identification and resolution of claims issues through thorough research using tools such as review of provider contracts, benefits, JIRA tickets, CES edits, NCCI edits, correct coding, and other appropriate tools.

• Acts as a claims subject matter expert (SME) and resource/support for claim edit and payment policy initiatives
• Conducts in-depth research on complex claim issues
• Conducts in-depth research on profile claim edits
• Documents research outcomes and makes recommendations to the Payment Policy team and PI leadership
• Follows up with appropriate individuals or areas to gather additional information related to any proposed or open initiatives
• Clearly document sources and validate the accuracy of data/information
• Identify process improvements to effectuate streamlined processes
• Documents root cause analysis and mitigation
• Represents Neighborhood to internal and external customers in a professional manner
• Attends ad-hoc and regularly scheduled meetings within the organization
• Team up with essential collaborators to outline project tasks, breakthroughs, and deadlines
• Collaborate with Payment Policy team for claim payment edits and claim editing software
• Assist in the development of provider payment policies including collaboration with Provider Relations and Configuration teams
• Monitor Centers for Medicare & Medicaid Services (CMS), Federal, State, industry standard, and software updates to ensure editing rules are in alignment with organizational needs for each product line
• Collaborates with other departments to identify and document root causes to resolve claim payment issues
• Opens JIRA tickets as needed
• Performs other duties/special projects as assigned
• Responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications Required:

• Bachelors degree or equivalent experience in a relevant field in lieu of a degree
• Minimum of five (5) years’ experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)
• One (1) or more years’ experience working in direct relation with the provider community (claim resolution, GAU, provider relations, contracting, etc.)
• Strong understanding and experience in all aspects of claims adjudication, processing, and analysis
• Ability to manage multiple projects simultaneously
• Ability to understand business systems and articulate deficiencies and opportunities in both claim processing systems;
  Health Rules and Amisys
• Understanding of provider reimbursement mechanisms
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
• Understanding of contract implementation and working knowledge of contract language
• Must exercise excellent judgment and be effective working autonomously and as part of a team
• Exceptional listening skills and verbal/written communication skills
• Problem solver with strong attention to detail
• Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors. (internal candidate)
• Must be knowledgeable of resources available within the organization to resolve both internal and external problems and concerns
• Must be able to…