Medicare Claims Processing Specialist

Company: Rxadvance Corporation
Location: Southborough
Posted on: January 27, 2023

Job Description:

Company Overview:

Join us in our mission to transform healthcare! RxAdvance, now doing business as nirvanaHealth, is committed to bringing the art of possible to the payer and PBM industries, which is why we strive to invest in our employees throughout all stages of life. Success radiates through all levels of employees here, with competitive benefits, a strong focus on employee wellness, and optional education courses offered through UDEMY: we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria - the first robotic process automation cloud platform designed for healthcare.

Led by our chairperson John Sculley (former Apple CEO) and noted healthcare entrepreneur and founder of ikaSystems Ravi Ika, nirvanaHealth endeavors to sizably reduce the $900 billion in waste in healthcare administrative and medical costs. We are seeking A-players to join our team - folks who embrace the grind and hustle of a growing company, are collaborative and innovate, are life-long learners and growers, and have an entrepreneurial and positive mindset.

This is a consultant position with full-time opportunity on a case by case basis

Job Summary :

The Claims Processing Specialist is responsible for training the team to analyze and process complex medical claims that require research to determine action steps and calculations necessary to make an accurate payment. The Claims Specialist will be responsible for training the team on how to research, solve and process all types of Medical Medicare claims. They will also be responsible for training the team on how to investigate, troubleshoot, and submit for processing all pended Medical Medicare claims. The Specialist may attend to assigned claims and reporting project on priority basis. Additionally, the trainer will be responsible for providing training support to one or more work streams within the operations and claims processing teams.

Primary Responsibilities (but not limited to):

Train the team on how to review, research, solve and process Medical Medicare claims. This would include navigating multiple computer systems and platforms (e.g. verify pricing, prior authorizations, applicable benefits).

Ensure that the team that is being trained knows proper benefits are applied to each claim by using the appropriate tools, processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents).

Responsible training the team on processing complex medical claims (professional and institutional). This includes but is not limited to; COB, high dollar, dialysis, DME, Behavioral Health, hospital exclusions, and claim adjustments in an accurate and expedient manner.
Training and mentoring of new team members.
Training members on testing of new claim processing procedures or projects.
Responsible for meeting performance measurement standards for productivity and accuracy.
Training the team on adjudication of claim adjustments.
Training in how to review and correct claims involving data integrity issues.
Interface with other departments, when necessary, regarding claims issues.
Assisting and collaborating with additional workstreams to ensure proper claims adjudication.
Training the teams on how to determine proper adjudication of primary and secondary payer claims based on member eligibility
Training the teams on how to process member reimbursement requests and analyzing / reporting member historical reimbursement requests
Collaborating with compliance team during departmental inquiries and provide subject matter expertise when necessary.

Skills/Qualifications:
Bachelor's degree or relevant experience in claims/customer service with Medicare Claims and Benefits Processing
CPC (Certified Professional Coder), preferred
2 years of experience in adjudicating medical claims in a Medicare Advantage setting
Medicare/Medicaid experience, preferred
Understanding of healthcare industry is required
Well versed with CPT, ICD-10 and HCPCS codes
Deep understanding and processing of CMS1500 and CMS1450 (UBO4)
Advanced verbal and written skills

Keywords: Rxadvance Corporation, Boston , Medicare Claims Processing Specialist, Other , Southborough, Massachusetts