Job FamilyClaimsJob Brief
The Senior Claims Specialist is responsible for accurate and timely claims analysis completion through resolution of various projects
The Senior Claims Specialist is responsible for accurate and timely claims analysis completion through resolution of various projects. Provides assistance and guidance to Claims Specialists that requires a higher level of technical skills and knowledge. Responsible for working Claims tickets timely and effectively. Works with Accounts Management around complex provider claim complaints. Attends calls as needed.Primary Responsibilities
• Responsible for investigating and resolving claim related tickets and other types of requests including but not limited to claim reprocessings and inquiries from internal and external sources
• Provides accurate and timely maintenance of the most complex provider and reimbursement information.
• Analysis of provider's trends and issues with reported findings
• Monitor, review and release of all claims batches in the Claims Management module in FlexCare. Includes: New, Queue, Pending and plan specific claims folders.
• Ensures all applicable batches are released in time for weekly check runs.
• Maintains thorough knowledge of the processing requirements for each Plan.
• Review and process member reimbursements
• Quality check claim batches adhering to weekly check run deadline
• Check refund processing
• Liaison with Mail Room team with claims related items.
• Review and process specialty batches
• Enter claims as needed
• Assist in post implementation process for new business.
• Liaison for Member Services related to escalated claim calls
• Assist in training of new staff
• Working knowledge of vendor relationships (3M and other vendors as contracted)
• Working knowledge of specialized pricing methodologies, I.E. 3M groupers - MS-DRG, APC, APGs, APR-DRGs.
• Create and maintain a manual documenting departmental tasks
• SOC remediation point person
• SOC remediation- ensures monthly SOC scores are tracked by plan, findings are resolved through to completion.
• SOC remediation- responsible to research claims outside of SOC purview however related to findings from SOC review. I.e. provider retro rate load/reprocess, ITR completion/follow through with identifying affected claims.
• Review, analyze post adjudication review findings and completes through resolution
• Serve as a back up to the Manager for specific functions.
• Represent the Claims department on calls as needed
• Strong leadership and interpersonal skills.
• Other duties as assignedEXPERIENCE/EDUCATION:
- Bachelor's Degree in Business, Healthcare Administration or related fields; or an equivalent combination of education, training and experience is required
- Minimum of five years' of related work experience;
- Ability to handle demanding caseload, make independent decisions and multi-task.
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Beacon Health Strategies, LLC., a Beacon Health Options company, is proud to be an Equal Opportunity Employer as well as a Drug Free Work Environment. EOE/M/F/Veterans/Disabled
AAP Reporting Location:MA - Woburn
ID (Req #):54008
FTE Status:Full Time