Apply on Employer Site

Neighborhood Health Plan of Rhode Island · 5 hours ago

Policy and Claims Research Specialist

Smithfield, RI

Full-time

Onsite

Senior Level

5+ years exp

Neighborhood Health Plan of Rhode Island is seeking a Policy and Claims Research Specialist to support their Payment Integrity initiatives and projects. This role will act as a claims subject matter expert, handling inquiries and conducting in-depth research on claims issues, while collaborating with various teams to ensure timely resolution of open issues.

Health CareMedicalNon Profit

Responsibilities

Acts as a claims subject matter expert (SME) and resource/support for claim edit and payment policy initiatives

Conducts in-depth research on complex claim issues

Conducts in-depth research on profile claim edits

Documents research outcomes and makes recommendations to the Payment Policy team and PI leadership

Follows up with appropriate individuals or areas to gather additional information related to any proposed or open initiatives

Clearly document sources and validate the accuracy of data/information

Identify process improvements to effectuate streamlined processes

Documents root cause analysis and mitigation

Represents Neighborhood to internal and external customers in a professional manner

Attends ad-hoc and regularly scheduled meetings within the organization

Team up with essential collaborators to outline project tasks, breakthroughs, and deadlines

Collaborate with Payment Policy team for claim payment edits and claim editing software

Assist in the develop of provider payment policies including collaboration with Provider Relations and Configuration teams

Monitor Centers for Medicare & Medicaid Services (CMS), Federal, State, industry standard, and software updates to ensure editing rules are in alignment with organizational needs for each product line

Collaborates with other departments to identify and document root cause to resolve claim payment issues

Opens JIRA tickets as needed

Performs other duties/special projects as assigned

Responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualification

Claims adjudicationManaged care experienceProvider reimbursement mechanismsMicrosoft OfficeJIRAHealthRulesHIPAA standardsInformation managementRoot cause analysisProcess improvementContract knowledgeCognosMedInsightSharePointOptum EncoderAAPC certificationProblem solvingCommunication skillsAttention to detailTeam collaborationProject management

Required

Bachelors degree or equivalent experience in a relevant field in lieu of a degree

Minimum of five (5) years' experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)

One (1) or more years' experience working in direct relation with the provider community (claim resolution, GAU, provider relations, contracting, etc.)

Strong understanding and experience in all aspects of claims adjudication, processing, and analysis

Ability to manage multiple projects simultaneously

Ability to understand business systems and articulate deficiencies and opportunities in both claim processing systems; HealthRules and Amisys

Understanding of provider reimbursement mechanisms

Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)

Understanding of contract implementation and working knowledge of contract language

Must exercise excellent judgment and be effective working autonomously and as part of a team

Exceptional listening skills and verbal/written communication skills

Problem solver with strong attention to detail

Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors. (internal candidate)

Must be knowledgeable of resources available within the organization to resolve both internal and external problems and concerns

Must be able to collaborate with business areas throughout the organization to insure resolution(s)

Must have strong information management skills including the ability to organize information, identify subtle and/or complex issues that impact customers

Must have the ability to articulate and pursue solutions with various Business areas to insure problem resolution of impacted service

Knowledge and understanding of HIPAA standards, CMS guidelines, EDI, UB04 and CMS 1500 data elements as well as NUBC requirements

Ability to partner on issue identification and resolution with outsourced entities