Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
Supports the overall 100% quality effectiveness to ensure that all claims are processed accurately and completely to insure appropriate adjustment code usage and payment rate.
Duties and Responsibilities
- Proficient with Federal requirements in claims processing.
- Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.
- Proficient in rate application for all CMS 1500 and CMS 1450 (UB04) claims for the Medicare line of business.
- Proficient in rate application for all outpatient & inpatient facilities, ASC, and all other payment methodologies that support the Medicare line of business.
- Must be able to verify that claims are paid by correct contractual provisions, regulatory guidelines, and all company and departmental policies and procedures.
- Must be able to work independently and successfully with limited supervision.
- Must be able to work with Claims Examiners, give direction, and answer claims-related questions to improve the overall quality of the department, and individual examiners.
- Performs “pre” and “post” audits for all department examiners, at all levels.
- Ability to take verbal as well as written direction from Claims Operations Manager.
- Can effectively use “Crystal reports” to capture deficiencies in processed claims before check run.
- Run valid reports and provide monthly reporting to the Claims Operations Manager of claims examiner’s production quality.
- Must keep individual Claims Examiner results at a confidential level between Auditor, Claims Examiner, and Claims Operations Manager.
- Makes recommendations to improve audit procedures and consistency throughout the year.
- Familiarize and comply with CMS (Medicare) timeliness guidelines (i.e. Medicare non-contracted claims 30 calendar days; Medicare contracted claims 60 calendar days).
- Proficient in and thorough understanding of the “Coordination of Benefits” concepts and rules. Proficient in, and knows how to use and apply Benefit Matrices and Division of Financial Responsibility (DOFR).
- Prompt and accurate response to claims-related questions from interdepartmental Supervisors, and Managers.
- Identify claims that fall under Third Party Liability (TPL), Reinsurance/Stop Loss, and potential Worker’s Compensation claims.
- Must have three years of claims processing and/or auditing experience.
- Internal audit experience is preferred.
- Must have the ability to work effectively with minimal supervision.
- Proficient in medical terminology, CPT, ICD9, Revenue codes, HCPCS codes
- Excellent verbal and written communication skills.
- Excellent organizational skills and interpersonal skills.
- Experience with EZ-CAP and other claims examining systems modules and functionality
We’re Making Healthcare Right. Together.
We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:
Focusing on Consumers
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
Building on Alignment
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.
Powered by Technology
We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.