82 applicants

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Company

tango · 23 hours ago

Analyst, Healthcare Claims Customer Service (Remote)

Phoenix, AZ

Full-time

Remote

Mid, Senior Level

5+ years exp

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Responsibilities

Manage all claims appeals, including disputes, redeterminations, and reconsiderations

Confirm reimbursement accuracy and work with Networks, Medicaid, and Medicare in any questions/concerns

Analyze claims activity and work reports received by Providers, Networks or Management

Perform claims reprocessing, reexporting and address medical billing issues

Assist with special reports of tracking problems with medical claims according to HIPPA guidelines, contracts, fee schedules and provide education to providers/internal staff as applicable

Apply knowledge of coding to determine if dispute is valid

Review documentation, analyze reject claim data, justify CPT & HCPCS codes and pay HCFA-1500 and UB92 claims.

Take inbound customer-service calls and make outbound calls to providers

Investigate pending claims and resolve discrepancies

Explains EDI claims transmissions and educates providers on rejection reasons and how to resolve the issue to ensure clean claim submissions

Contacts providers to provide necessary billing guidelines to comply with quality and process standards

Follows established guidelines specific to each claim report or inquiry

Review, coordinate and respond to all request or record requests in a timely order

Responsible for delivery of EOP’s to providers after each claim run

Responsible for investigating clearinghouse rejections, ensuring rejection letters are accurate and of high quality

Responsible for collaborating with Networks on escalating all high-volume rejection/denial claims by provider as communicated in Bi-weekly Claim Dashboards and providing an improvement plan on submission of clean claims for timely payments

Take part in the monthly Claim Webinar Training to our Network

Oversees review of claims inventory for quality and findings in external audits from all Payors/Providers as well as annual internal audit in accordance with tango Claims Policies and Procedures

Handling of all claim escalations (verbal and electronic) in accordance with tango Claims Policies and Procedures

Escalating all high-volume Provider Claim issues to ensure positive rapport with our network Providers in accordance with tango Claims Policies and Procedures

Mentoring new team members and providing assistance and review of quality of work during onboarding

Perform other duties as assigned within the scope of responsibilities and requirements of the job

Performs the essential functions of this job with or without reasonable accommodation

Qualification

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Claims AdjudicationMedical CodingClaims ProcessingTechnical System OperationsMicrosoft OfficeMicrosoft ExcelWeb Reports

Required

5 to 7 years of direct experience minimum in Claims Adjudication and Clearinghouse submissions/rejections

Advanced level of skills and knowledge of technical system operations

Detailed knowledge of medical coding; HIPPS, CPT and HCPCS codes

Solid understanding of enrollment and eligibility as well as claims paying for all lines of business

Solid understanding of claim data sets required on Encounter Files to ensure resubmission of claims/disputes are in accordance to 837 CMS regulations

1-3 years working in a claims inbound call center

Professional level training that provides a general understanding of: Administration of all contractual obligations, Audit and billing procedures, Policies and procedures, Processing of accounts receivable and eligibility requirements impacts claims processing, Vendor data feeds and discrepancy process, Administrative and regulatory requirements, Technical workflow processes, Functional requirements of the system, Solution design documents.

4 to 6 years work experience that provides a working knowledge of: Billing and delinquency procedures, Accounts receivable process, System testing and enhancement process, Web portal data support

Advanced level Microsoft Office skills (PowerPoint, Word, Outlook)

Advanced level Microsoft Excel skills

Advanced level of Web Reports and how to read 837 files to support working of encounter rejections

Interpersonal, communication (written and verbal) and presentation skills

Analytical, research, problem solving, and decision-making skills

Ability to monitor team goals

Ability to lead and coach team members