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MetroPlusHealth · 1 hour ago

Claims Adjustment Specialist I

New York, NY

Full-time

Onsite

Entry, Mid Level

2+ years exp

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. The Claims Adjustment Specialist I will be responsible for analyzing and adjusting healthcare claims to ensure payment accuracy and mitigate errors, while maintaining accurate records and responding to provider inquiries.

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Responsibilities

Research and analyze medical claims adjustment requests along with related documentation to determine payment accuracy and adjust/adjudicate as needed using multiple systems and platforms

Ensure that the proper payment guidelines are applied to each claim by using the appropriate tools, processes, and procedures (e.g., claims processing P&P’s, grievance procedures, state mandates, CMS/Medicare/Medicaid guidelines, benefit plans, etc.)

Research claims that may have paid incorrectly and communicate findings for adjustment; Adjust claims based on findings (i.e., correct coding, rates of reimbursement, authorizations, contracted amounts etc.) ensuring that all relevant information is considered

Advise business partners of findings outcome if their input is needed to help fix the issue

Communicate through correspondence with providers regarding claim payment or additional required information in a clear and concise manner

Process the adjustment of claims in a timely manner, according to established timelines

Remain current with changes/updates in claims processing, as well as updates to coding systems

Maintain accurate records of all claims processed, including notes on actions taken

Generate reports on claim activity as requested

Respond to audits of claims processed

Able to work independently and exercise good judgment

Qualification

Claims processingData entryMedical terminologyCPTICD-10 knowledgeCRM softwareAnalytical skillsTrustMS WordExcelWritten communicationOral communicationIntegrityCustomer focus

Required

High School Degree or evidence of having passed a High School Equivalency Program required

Minimum 2 years of claims operations experience in a healthcare field, with knowledge of integrated claims processing required

Experience using a PC and claim adjudication system(s)

Experience using Customer Relationship Management (CRM) software; Salesforce is a plus

Experience working with large data and spreadsheets

Knowledge of medical terminology, CPT, ICD-10, and Revenue Codes

Processing of Medical Claim Forms (HCFA, UB04)

Knowledge of Medical Terminology

Knowledge of HIPPA Guidelines regarding Protected Health Information

Data Entry of Provider Claim/Billing information

Experience handling or familiarity with Medical Claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators

Integrity and Trust

Customer Focus

Functional/Technical skills

Written/Oral Communication

Strong Analytical Skills

Knowledgeable in MS Word and Excel