The Claims Customer Service Analyst is accountable for and oversees the following tasks:
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
Essential Job Functions And Duties
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 PHCN Claims Policies and Procedures
Handling of all claim escalations (verbal and electronic) in accordance with PHCN Claims Policies and Procedures
Escalating all high-volume Provider Claim issues to ensure positive rapport with our network Providers in accordance with PHCN 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
Essential Qualifications
Years of Experience and Knowledge
5 to 7 years of direct experience minimum in Claims Adjudication and Clearinghouse submissions/rejections (required)
Advanced level of skills and knowledge of technical system operations (required)
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 (required)
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
Skills And Abilities
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
Job Type
Full-time
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other
Industries
Hospitals and Health Care
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