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MetroPlusHealth · 1 week ago

BH Claims Service Representative

New York, NY

Full-time

Onsite

Mid Level

$50K/yr - $56K/yr

4+ years exp

MetroPlusHealth is seeking a BH Claims Service Representative responsible for addressing Behavioral Health claim inquiries. The role involves research and analysis of claims, ensuring payment accuracy, and collaborating with various departments to resolve issues efficiently.

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Responsibilities

Research and analyze BH claims inquiries and adjustment requests to determine payment accuracy

Adjust/adjudicate as needed using multiple systems and platforms

Ensure the proper payment guidelines are applied to each claim by using the appropriate tools, processes, and procedures (e.g., claims processing P&P's, job aids & desk level procedures, reconsideration/appeals procedures, state mandates, CMS/Medicare/Medicaid/OMH guidelines, benefit plans, etc.)

Coordinate, follow-up and track appropriate problem resolution activities with all appropriate staff to ensure timely resolution

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

Work with the management team to stay updated on claims processing criteria, regulatory updates, new benefits and/or products and be informed of any changes in company policies

Impact the company's bottom line by problem solving and turning frustrated customers into contented customers

Participate in 'special' projects as required

Qualification

Behavioral health claims processingClaims processing systemsCustomer Relationship ManagementPowerSTEPPHealthRules PayerSalesforceTrustAnalytical skillsFunctional/Technical skillsQuality workJudgmentIntegrityCustomer FocusWritten/Oral Communication