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NeighborHealth · 3 hours ago

Analyst, Claims

Revere, MA

Full-time

Onsite

New Grad, Entry Level

$26/hr - $39/hr

NeighborHealth is one of the largest community health centers in the country, committed to serving the greater Boston area. The Claims Analyst is responsible for the overall claims adjudication and insurance validation process, including maintaining knowledge of fee schedules, auditing claims, analyzing data, and coordinating with various departments to ensure compliance and efficiency.

Child CareElder CareHealth CareMedicalPrimary and Urgent Care

Responsibilities

Maintaining up-to-date knowledge of fee schedules for both Medicare and MassHealth

Ensuring the fee schedules are updated and are priced correctly in the Tapestry module

Auditing adjudicated claims to ensure payments are made in accordance with their contracts

Analyzing claims data to ensure accruals are reported to Finance in a timely and accurate manner

Ensuring accuracy of claims-related cost reports

Analyzing claims data for trends (e.g., referral matching)

Reporting any findings to PACE leadership

Coordinating with IT to enhance and refine the claims adjudication process

Coordinating with the Manager of PACE Claims to proactively review referrals and claims-related data in an effort to provide utilization reports to other departments

Must maintain up-to-date knowledge of Coordination of Benefits

In conjunction with the Supervisor of Business Services, responsible for assisting with and developing workflows to maintain overall compliance of the Insurance Department

Serves as the department Medicare expert. This includes auditing enrollment files to ensure compliance with the Part D requirements: EOBs, COB follow-up is completed timely and accurately, as well as documentation in EPIC regarding MSP surveys and TrOOP

Ensures primary insurance coverage is documented in EPIC and that insurance billing is appropriate

Responsible for the timely completion and documentation of CMS Part D reports: COB, MSP

Serves as back-up for Business Services Supervisor

Monitors monthly expense reports to ensure that all expenses are correctly categorized and reported

Oversees the referral authorization process as it relates to timely and accurate claims payment and improvements to utilization management

Responsible for maintaining up-to-date knowledge of fee schedules and works with IT to ensure timely upload into Tapestry

Coordinates with the Manager of PACE Claims in an effort to improve the processes to manage claims payment and expenses based on trends analysis

Acts as the department claims expert regarding adjudication

Audits claims work queues to ensure timely and appropriate payment to vendors; suggests process improvements (e.g., referral matching table edits)

Coordinates with Finance to ensure appropriate accruals on a monthly basis. Reviews IBNR data with Finance in an effort to ensure all claims are received

Works closely with the Contracts Department to review reimbursement

Serves as a liaison with IT, specifically regarding Tapestry (fee schedule development, claims processing, referrals) and reports and workflows related to ESP (Elder Service Plan) Business Office processes

Regularly reports to work on time and follows attendance and call-in procedures

Works cooperatively and respectfully with others at all levels of the organization

Takes the initiative to perform a wide variety of activities and be flexible in terms of work assignments based on operational needs, contributing to the smooth functioning of the department

Displays outstanding customer service skills when interacting with all NH customers according to the PACE model

Creates and/or revises policies and procedures, workflows, and guidelines, as appropriate, in any respective areas under the Business Office or as requested by Manager

Other duties as required

Qualification

Claims adjudicationInsurance validationTapestry moduleCoordination of BenefitsClaims data analysisCustomer serviceTeamworkCommunication skills

Required

Maintaining up-to-date knowledge of fee schedules for both Medicare and MassHealth

Ensuring the fee schedules are updated and are priced correctly in the Tapestry module

Auditing adjudicated claims to ensure payments are made in accordance with their contracts

Analyzing claims data to ensure accruals are reported to Finance in a timely and accurate manner

Ensuring accuracy of claims-related cost reports

Analyzing claims data for trends (e.g., referral matching)

Reporting any findings to PACE leadership

Coordinating with IT to enhance and refine the claims adjudication process

Coordinating with the Manager of PACE Claims to proactively review referrals and claims-related data in an effort to provide utilization reports to other departments

Must maintain up-to-date knowledge of Coordination of Benefits

In conjunction with the Supervisor of Business Services, responsible for assisting with and developing workflows to maintain overall compliance of the Insurance Department

Serves as the department Medicare expert

Auditing enrollment files to ensure compliance with the Part D requirements: EOBs, COB follow-up is completed timely and accurately, as well as documentation in EPIC regarding MSP surveys and TrOOP

Ensures primary insurance coverage is documented in EPIC and that insurance billing is appropriate

Responsible for the timely completion and documentation of CMS Part D reports: COB, MSP

Serves as back-up for Business Services Supervisor

Monitors monthly expense reports to ensure that all expenses are correctly categorized and reported

Oversees the referral authorization process as it relates to timely and accurate claims payment and improvements to utilization management

Responsible for maintaining up-to-date knowledge of fee schedules and works with IT to ensure timely upload into Tapestry

Coordinates with the Manager of PACE Claims in an effort to improve the processes to manage claims payment and expenses based on trends analysis

Acts as the department claims expert regarding adjudication

Audits claims work queues to ensure timely and appropriate payment to vendors; suggests process improvements (e.g., referral matching table edits)

Coordinates with Finance to ensure appropriate accruals on a monthly basis

Reviews IBNR data with Finance in an effort to ensure all claims are received

Works closely with the Contracts Department to review reimbursement

Regularly reports to work on time and follows attendance and call-in procedures

Works cooperatively and respectfully with others at all levels of the organization

Takes the initiative to perform a wide variety of activities and be flexible in terms of work assignments based on operational needs

Displays outstanding customer service skills when interacting with all NH customers according to the PACE model

Creates and/or revises policies and procedures, workflows, and guidelines, as appropriate, in any respective areas under the Business Office or as requested by Manager

Demonstrates commitment to the PACE mission by actively promoting the autonomy and dignity of PACE program participants

Demonstrates commitment to a holistic approach to care by actively engaging in interdisciplinary team planning and communication processes

Demonstrates commitment to participant-centered care by actively engaging participants and/or Health Care Proxies in discussion about self-management goals

Understands ESP's organizational structure

Demonstrates the ability to communicate effectively and respectfully through verbal and written skills

Documents in accordance with protocol

Demonstrates knowledge of Participant Rights

Promotes a sense of 'teamwork' through demonstration of self-direction and self-motivation

Solves problems independently or knows when to seek consultation

Provides leadership to other support staff on the practice team

All ESP employees participate in the orientation, training, and mentoring of new employees and in providing input for continuous improvement

Displays outstanding customer service skills when interacting with ESP participants, family members, outside providers, potential ESP members, referral sources, or others

Interacts with participants in a professional and respectful manner that reflects the needs and concerns of the individual

Maintains a positive attitude

Uses communication devices appropriately

Demonstrates commitment to performance improvement by reporting incidents and other data used in ESP Performance Improvement activities

Actively participates in one or more performance improvement committees or making a minimum of two suggestions for program or other improvements over the course of the year

Responsible for continued professional growth and development