The Claims Research Analyst reviews and monitors adjudicated claims for file submission and upstream processing and communicates with provider agencies on claims submission, denial management, and system updates. This position serves to provide excellent customer service to provider agencies. This position facilitates training of providers and provides intermediate technical assistance. This position reviews auto-adjudicated claims and manually processes claims that pend for manual pricing or high impact criteria. This position analyzes available billing requirements, policies, procedures, and desk references to ensure proper protocol is practiced to accurately process claims. The CRA demonstrates and utilizes advanced analytical skills to process complex claims, analyze data, identify system issues, and utilize/build reports to enhance overall unit performance. This position aids in the leadership of the unit through facilitation of meetings, trainings, and process improvement efforts. The position requires the application of technical skills, communication across all departments including Utilization Management, Provider Networks, Finance (Purchasing, Accounts Payable, Accounting), Care Management). The position requires communication with external stakeholders including DHHS, DSS, DHB, provider agencies, third-party vendors, and other Managed Care Organizations. The position requires a high degree of professionalism and productivity.
Responsibilities & Duties
Process Claims
Review, key, process, status, track, and file Special Invoicing claims submissions which requires skill in managing and reconciling data between two information systems (finance/claims)
Receive, review, analyze claims submitted via paper process to determine ability to process. If processable, key the claims accurately into the claims system
Review and analyze received claims to determine accuracy of adjudication
Identify adjudication errors, provider billing errors, and needs for technical assistance
Monitor adjudication results using provided reports
Apply basic claims knowledge in the review of patient and provider accounts to determine if account updates are needed
Apply knowledge of eligibility, enrollment, prior approval, contracts, and credentialing to identify account needs
Using existing reports, assure claims are processed within prompt payment guidelines
Using Compliance Unit’s reversion packets, process refunds or adjustments
Review claims for appropriate service event authorizations, consumer eligibility, and routine billing requirements
Ensure appropriate coordination of benefits has occurred utilizing billing and payment policies and procedures
Manually process claims unable to be adjudicated properly within MCS; including linking claims that error to the Exceptions Report
Monitor and resolve technical issues within the Claims system
Utilizing existing reports, monitor, track, and resolve Patient Monthly Liability corrections on provider claims and within NCTracks
Review policy requirements associated with new or additional services to be processed and apply the knowledge to the processing of associated claims
Reporting
Utilize reports to identify and resolve claims errors or updates
Create reports to monitor status of billing, including: paid and denied provider claims; unmanaged and managed service utilization, and consumer or payer-specific reports on claims reimbursement or adjudication
Communication
Communicate and conduct liaison work across multiple departments to resolve claims denials/issues
Communicate with high level external stakeholders like DHB, DHHS, and DSS
Communicate with internal stakeholders (all departments)
Communicate with provider agencies
Demonstrate professional and timely communication
Provider Support
Provide training, education, and technical assistance to provider agencies related to basic claims submissions guidelines, denial management, MCS system use and updates, state/federal claims submissions regulations and updates
Develop training materials to facilitate trainings
Assist with Claims Process Improvement
Identify resolution of system errors, review impact reports, communicate with providers and determine steps for reconciliation
Provide information and feedback to the system team to support development of system enhancements in a structured manner aimed to eliminate system settings and or processes that contribute to poor results
Maintain processes that are consistent with and compliant to CMS, state, federal and URAC standards, regulations and guidelines
Read, review, analyze, and apply information from published clinical coverage policies and other NCDHHS documents to ensure the claims system and manual processes are incorporating required actions
Data Analytics
Demonstrate high level understanding of data; effectively utilize data mining tools; build report parameters
Leadership
Demonstrate leadership abilities through independent work, role modeling for peers, taking initiative with tasks and process improvement activities, engages in all aspects of claims actions
Provide first level consultation to peers
Support Expansion and New Business
Learn new skills related to expansion and new business requirements per Alliance Health contracts. This includes: coverage of additional catchment areas, new covered services, processing and handling of physical health claims
Technical
Apply claims processing skills. Apply detailed knowledge of how the Alliance Claims System (ACS) works. Identify ACS system issues, create tickets, strategize solutions with IT Development team, track tickets, communicate resolutions to providers. Analyze impact reports and follow resolution efforts through claims reconciliation
Minimum Requirements
Education & Experience
High School degree or equivalent and four (4) years of related experience (in customer service, claims processing, research/analytics, or communications);
Or
Bachelor’s degree from an accredited college or university in related field and two (2) years of experience (in customer service, claims processing, research/analytics, or communications).
Preferred:
Experience with Medicaid and IPRS preferred.
Knowledge, Skills, & Abilities
Knowledge of Microsoft Office, including Excel, Word, Outlook
Working knowledge of healthcare services and systems
Working knowledge of functions provided by Provider Networks, Utilization Management, Accounts Payable, Contracts, and Care Management
Knowledge of common claims denials and sources for correction
Knowledge of Medicaid and IPRS rules
Knowledge of laws, legal codes, precedents, government regulations, and MCO policies and procedures
Knowledge of medical terminology, CPT/HCPCS/UB04 revenue coding, modifiers, and billing regulations
Excellent customer service skills
Proficiency in written and oral communication sufficient for the sharing of technical information
Strong organizational skills
Ability to set objectives and prioritize workflow
Ability to document clearly and accurately
Ability to solicit cooperation from persons and departments throughout the organization
Ability to adhere to department policies, procedures, and general practices
Ability to work independently and as part of a team
Ability to demonstrate professional conduct in all situations
Ability to take initiative
Ability to solve complex problems through the evaluation of alternative methods and solutions
Ability to develop strong working relationships with divergent groups and communicate technical concepts to lay persons
Ability to utilize efficient practices to complete assigned workload
Ability to demonstrate professional presentation and conduct at all times
Ability to independently follow instructions or desk procedures accurately and without error
Salary Range
$22.23 - $28.34/hourly
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
