Claims Researcher - Medicare
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 Claims Researcher can be responsible for the timely and accurate adjudication of claims. Review and resolve pended and corrected issues on claims. Analyzes claim resubmissions request / disputes to determine appropriateness via the plans policy and procedures. Serve as the primary point of contact for claim issues raised by Providers and internal departments. Provide feedback on department workflows and identifies opportunities for redesign. Performs claims testing to ensure that systems are designed efficiently based on the Plan's benefit structure.
- Confirm claim data accuracy and timely submission, in alignment with departmental production and quality goals
- Maintain established levels for accuracy and productivity
- Confirmed claim submissions for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding)
- Confirm claims are correctly adjudicated for contracted / non-contracted providers; Confirm policies and procedures were utilized to meet claim 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
- Review medical/surgical billings for reasonable and necessary charges and examine valid payment for coding of operative, procedures, and multiple and complicated surgeries.
- Verify presence of all required data fields and that applicable medical records are included/reviewed (where required)
- Process request from internal / external customers to confirm claim processing verification for accuracy
- Rectify issues concerning claims processed with config issues and follow up correction of the misconfigured system / benefit
- 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
- Provide second review of claims on which providers question appropriateness / accuracy of payment made to provider
- 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
- Associated degree preferred or equivalent experience
- Minimum of three years’ experience in healthcare claims processing, or an equivalent combination of education, training and experience
- Knowledge of medical reimbursement policies, procedures and standards.
- Knowledge of health care billing standards and procedures.
- 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 data analysis methods.
- Knowledge of CPT Codes, HCPCs and ICD-10 codes
- Medicaid and Medicare experience preferred