This job is a primary resource that coordinates, analyzes, and interprets the benefits and claims processes for clinical teams and serves as the liaison between the department and the claims processing departments to facilitate care/case management activities and the processing of pay-by exception and special handling claims. The person in this position must fully understand all product offerings available to Organization members and be versed in claims payment methodologies, benefits administration, and business process requirements.
- Coordinate, analyze, and interpret the benefits and claims processes for the department.
- Serve as the liaison between the department and the claims processing departments to facilitate care/case management activities and the processing of pay-by exception and special handling claims. Communicate benefit explanations clearly and concisely to all pertinent parties.
- Investigate benefit/claim information and provides technical guidance to clinical and claims staff regarding the final adjudication of complex claims. Research and investigate conflicting benefit structures in multipayor situations.
- Provide prompt, thorough and courteous replies to written, electronic and telephonic inquiries from internal/external customers (i.e., clinical, sales/marketing, providers, vendors, etc.) Follow-up on all inquiries in accordance with corporate and regulatory standards and timeframes.
- Must have the ability to apply knowledge about the business operations of the area within the defined scope of the job. Assesses benefit limitations in accordance with Medical Policy Guidelines.
- Monitor and identify claim processing inaccuracies. Trends are brought to the attention of management.
- Other duties as assigned or requested.
- High School diploma or GED.
- Experience is needed in health care claims, health insurance and benefit administration
- PC proficiency
- Ability to communicate effectively in both verbal and written form
- Associates degree in or equivalent training in Business or a related field
- Knowledge of Highmark products and operations and previous experience in customer-focused activities in a business environment
- Working knowledge of medical procedures and terminology.
- Complex claim workflow analysis and adjudication.
- ICD9, CPT, HPCPS coding knowledge/experience.
- Knowledge of Medicare Policy.
- System knowledge: OSCAR, ICIS, MaxMc, Alineo
- Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services
- Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, designing forms and other office procedures
- The ability to take direction, to navigate through multiple systems simultaneously
- The ability to interact well with peers, supervisors and customers
- Understanding the implications of new information for both current and future problem-solving and decision-making
- Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate and not interruption at inappropriate times
- Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems
- Ability to solve complex issues on multiple levels.
- Ability to solve problems independently and creatively.
- Ability to handle many tasks simultaneously and respond to customers and their issues promptly.
- Possess good written and oral communication skills.
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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