Medicare Claims Processing Specialist
Company: Rxadvance Corporation
Location: Southborough
Posted on: January 27, 2023
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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
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