Senior Claims Processor
Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.
Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina. In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.
The Senior Claims Examiner adjudicates incoming claims in accordance with policies, procedures and guidelines, as outlined by Clear Spring Health and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts. The Senior level examiner is responsible to adjudicate complex claims, requiring additional research or problem solving. The examiner works with junior staff as a coach and mentor and leads special projects for management as needed. Hybrid schedule working onsite three days offsite two days.
- Accurately providing information to all incoming inquiries regarding claims, provider contracting and reimbursement, product information, procedures, and regulations
- Efficiently maneuvering through various computer systems and on-line resources in retrieving information while responding to customer inquiries and processing member, provider and internal stakeholders
- Assists in managing claims inventory to ensure that claims are adjudicated in an accurate and efficient manner
- Effectively ensure that detailed electronic records are maintained by accurately documenting all actions taken.
- Meeting measurable department standards as they relate to call quality, claim accuracy and efficiency measures as well as meeting teamwork, ownership, and professional development goals
- Learning, retaining, and updating one's knowledge of a wide variety of product information and internal processes and procedures, while adhering to CMS rules and regulations.
- Efficiently utilizing all resources to ensure they are easily accessible when providing information to a client, or supporting a junior teammate, or manager
- Performs thorough review of pending claims for billing errors and or questionable billing practices that might include duplicate billing and unbundling of services.
- Responsible for manually correcting system generated errors prior to final claims adjudication.
- Be proactive and articulate findings and potential solutions.
- Review requests submitted by customer service team timely and follows up with providers as necessary and directed by management.
- Pre-screen all claim types for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding)
- Correctly adjudicate claims for contracted/non-contracted providers; Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with contractual guidelines
- Review respective coding (i.e. CPT, HCPCS, ICD-10) to ensure that claims are billed in compliance with CMS and Correct Coding guidelines
- Verify presence of all required data fields and that applicable medical records are included/reviewed (where required)
- Identify and handle third party liability (TPL) or coordination of benefits (COB) issues
- Refer claims for medical claim review as necessary/applicable
- Identify and refer potential fraud and abuse cases to the Compliance Department
- Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs
- Identify opportunities for claims adjudication process improvements
- Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
- Ability to read, write and communicate at a professional level
- Effective time management and organizational skills
- Effective interpersonal and communication skills
- Other duties and responsibilities as may be assigned.
- Display actions that align with our Vision, Mission, and Values
- Minimum of five years’ experience in healthcare claims processing, audits or appeals, or an equivalent combination of education, training and experience with a health plan, health system or insurance carrier
- Computer proficiency in a Windows environment, knowledge of Microsoft Office products
- Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
- Strong knowledge of medical terminology
- Knowledge of CPT Codes, HCPCs and ICD-10 codes
- Medicaid and Medicare experience required
- Candidate must be detail oriented with strong organization and prioritization skills
- Strong commitment to customer service and quality required
- Proven decision-making skills and ability to multi-task required
- Willingness to coach junior staff and lead special projects as needed
- Effective analytical, problem solving and mathematical skills
- BA/BS degree preferred, or equivalent experience required
- Available to work a shift that starts at 8am or later