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Knowledge Specialist

1 month ago

Pune, India Mphasis Full time

Job Description

Senior Claims Examiner and Benefit Configuration Analyst

Under the supervision of the Claims Manager, the Senior Claims Examiner and Benefit Configuration Analyst is responsible for analyzing and processing claims and meeting defined quality and productivity standards.

As s benefit configuration analyst you would support cross-functional teams during implementations and build and manage benefit plans on various platforms to ensure a high quality product. This role will also be responsible for supporting the Plan Operations team with core benefits operations functions while building and maintaining accurate benefit configuration.

Process Skills:

 Work with clients, identifying and understanding benefit plan requirements. Build and maintain benefit plans for client groups.

 Aid in the organization of benefit configuration and structure for the accounts assigned by monitoring plan data integrity.

 Assist in determining process improvement efforts

 Maintain prior authorizations and step therapy rules.

 Collaborate with member support and customer success teams to review and resolve inquiries related to benefits timely to improve member experience.

 Provide troubleshooting support for our claims adjudication process.

 Support new client implementations conduct go-live testing, perform post go-live auditing and support to ensure plans are configured to confirm accuracy.

 Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines

 Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims

 Accurately analyzes and interprets provider contracts

 Researches claims and makes appropriate adjustments

 Assists with system configuration and testing for new clients

 Assists with testing of new processes, and provides feedback

 Reviews and tests fee schedules

 Reviews and approves batch close reports for examiners

 Analyzes and authorizes high dollar claims

 Determines appropriate payment for claims submitted for reconsideration (payment appeals)

Behavioral Skills :

 Assists with training new or existing staff, as requested

 Responds to clients inquiries related to claims processing

 Communicates clearly and concisely, with sensitivity to the needs of others

 Execution-focused ethos – solutions oriented problem solver and efficiency driven.

 Flexible, dependable, adaptable and able to respond under pressure of fast paced technology company.

 Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards; will support the success of the entire team; establishes and maintains effective working relationships with co-workers

 Follows all Policies and Procedures and HIPAA regulations

 Maintains a safe working environment

 Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees

 Establishes and maintains effective working relationships with co-workers

 Participates in any required training sessions/seminars

 Participates in special projects as requested

Certification:

 Education/Experience – Educational requirements include a high school diploma or equivalent. Five years of PACE plan management and/or claims processing knowledge required, along with current knowledge of Peak systems

 Requires working knowledge of ICD-10, CPT, Revenue, and HCPCS coding, along with understanding of APC and DRG reimbursement

 Self starter mentality, ability to make informed decisions, find creative approaches to difficult challenges and deliver on commitments.

 Requires knowledge of current computer technology, including the use of computers; knowledge and proficiency with associated software, including Excel and Word

 Skilled in establishing and maintaining effective working relationships with co-workers and clients

 Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency

 Detail-oriented with ability to focus for extended periods

 Ability to work independently, seeking supervision as needed

 Ability to communicate professionally, clearly and effectively, verbally and in writing

 Ability to meet attendance requirements to effectively fulfill all functions of the position

 Ability to independently follow through on assigned tasks, without prompting

 Ability to prioritize effectively and multitask

Physical Demands & Requirements

 Communicates by way of the telephone with participants, customers, vendors and staff

 Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer

 Remains stationary for extended periods of time

 Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects

 Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy

 Frequent, repetitive use of hands/fingers entering information on a keyboard

 Occasional reaching to retrieve shelved items

Work Environment

 This job operates in a home-office environment, or a professional office environment with a conversational noise level.

 No substantial exposure to adverse environmental conditions is expected

 Moderate pressure to meet scheduled appointments and deadlines

 Potential for occasional verbal aggression by clients and vendors

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