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Job Description

THE POSITION.

This position is responsible for reviewing and processing claims, including facility claims, to ensure accuracy prior to payment release. This position is the lead responder to Health Plans and IMS Clients for all products and lines of business. Responsible for management and monitoring of claims compliance with all products and lines of business for managed care claims payments. This person is the liaison with internal clients to resolve claim processing issues. Responsible to train claims examiners and is a resource relating to claims guidelines.

THE SPECS.

• Full-Time.
• Non-Exempt.
• Mid-Level Position.
• Hybrid: In-office and Remote.
• Benefits-Eligible: PTO, PSL. Holidays, Medical, Dental, Vision, and more.
• Requirement: Claims Processing experience, Facility Claims knowledge and processing, experience in Health Plan, Managed Service Organization, IPA.
• Pay Range: Starting $33 per hour, depending on experience, knowledge, and skills. Discussable.

THE DUTIES.

• Perform, process, and assist in processing facility claims and other claim payments according to department policies and procedures.
• Conduct daily audits following Claims Department Policies and Procedures and offer support and training as required.
• Analyze EOBs, adjust claims according to processing criteria, and perform pre-check run audits on check run schedules.
• Lead appeals to insurance carriers, monitor accounts for accurate fee postings to optimize office collections while minimizing adjustments.
• Respond and justify appeals as to why claims, services, or treatment should be paid.
• Communicate issues and suggestions for process improvements and resolve claims in compliance with CMS guidelines and Company Policies.
• Utilize and resolve claims based on CCI edit report to comply with CMS guidelines.
• Act as a resource for other departments on claims issues, participating in meetings and maintaining a fair work environment, while executing additional duties assigned by management.
• Conduct internal reviews to ensure compliance with regulatory and contractual standards in the claims system.
• Generate comprehensive reports from audit findings, identify trends, and implement strategies to enhance business processes and maintain quality standards.
• Assist to development of standardized audit procedures for recovery opportunities in collaboration with relevant departments.
• Actively engage in meetings and act as a resource regarding claims.
• Effectively communicate audit discoveries and propose solutions across all organizational levels.
• Foster a culture of teamwork and productive relationships to facilitate cohesive and efficient operations throughout the organization.
• Ensure compliance with company policies and procedures, as well as State, Federal and other regulatory bodies.
• To contribute to a fair and positive work environment by treating peers, superiors, subordinates, clients, and vendors with professionalism and respect.
• Performs other duties as assigned by management.

*Please note that the duties and responsibilities outlined above are summarized and may not encompass all tasks associated with the position. The nature of the role may require adaptation to changing circumstances and additional responsibilities not explicitly mentioned here. The organization reserves the right to modify, interpret, or supplement the job duties as needed.

THE COMPANY.

Innovative Management Systems is a management services company focused on finding innovative ways to ensure regulatory compliance, customer services, provider experience, and measurable outcomes in the healthcare industry. Through our ever-evolving data analytics platform, we strive to improve overall medical spending, HEDIS, and STAR measures through a collaborative effort of education, reporting and workflow management. Come be part of the team that helps to improve quality of care, reduce administrative burden, and achieve greatness through creative thinking and educated calculated risks. Be the change in healthcare everyone talks about, but few people achieve. We value our team's opinions and new ways of getting the job done and are looking for self-starters with fresh ideas, ready to help pave the way to a better tomorrow.

We are an Equal Opportunity Employer and seek diversity in our workforce. We are also an E-Verify Employer, you can learn more about E-Verify program and your rights and responsibilities here: Learn More About E-Verify.

EDUCATION.

• Associate Degree or 2-3 years of related experience, and/or training or equivalent combination of education and experience.

EXPERIENCE.

• Minimum of 5+ years as a "Medical Claims Auditor," in a health plan, managed service/care organization, IPA.
• Experience working with MediCare/Medicaid/Managed Care claims.

SKILLS, KNOWLEDGE, ABILITIES, OTHER CHARACTERISTICS

• Knowledge of Healthcare regulations and guidelines including: CMS, DMHC, DHS.
• Knowledge of Correct Coding Initiative, HCFA - 1500 and UB-92 claim forms and CPT Coding,
• Technical and computer expertise.
• Active communication and analysis/auditing skills to be able to identify and effectively communicate unresolved problems to Management in a timely manner.
• Ability to work with minimal supervision, and be able to be a team player to assist claims inquiries if needed.
• Detail-orientation and organized.
• Ability to adapt/change in fast-paced environment.
• Ability to work sitting down about 7+ hours in a workday.
• Accurately type and input data utilizing computer skills.
• Ability to learn software/database systems quickly.

Compensation details: 33-40 Hourly Wage

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