Claims Adjustment Specialist I

Position Overview

MetroPlusHealth provides healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island. As a wholly-owned subsidiary of NYC Health + Hospitals, MetroPlusHealth's network includes over 27,000 primary care providers, specialists, and participating clinics.

Duties & Responsibilities

• Research and analyze medical claims adjustment requests along with related documentation to determine payment accuracy and adjust/adjudicate as needed using multiple systems and platforms.
• Ensure that the proper payment guidelines are applied to each claim by using the appropriate tools, processes, and procedures (e.g., claims processing P&P’s, grievance procedures, state mandates, CMS/Medicare/Medicaid guidelines, benefit plans, etc.).
• Research claims that may have paid incorrectly and communicate findings for adjustment; Adjust claims based on findings (i.e., correct coding, rates of reimbursement, authorizations, contracted amounts etc.) ensuring that all relevant information is considered.
• Advise business partners of findings outcome if their input is needed to help fix the issue.
• Communicate through correspondence with providers regarding claim payment or additional required information in a clear and concise manner.
• Process the adjustment of claims in a timely manner, according to established timelines.
• Remain current with changes/updates in claims processing, as well as updates to coding systems.
• Maintain accurate records of all claims processed, including notes on actions taken.
• Generate reports on claim activity as requested.
• Respond to audits of claims processed.
• Able to work independently and exercise good judgment

Minimum Qualifications

• High School Degree or evidence of having passed a High School Equivalency Program required. Associate degree preferred.
• Minimum 2 years of claims operations experience in a healthcare field, with knowledge of integrated claims processing required.
• Experience using a PC and claim adjudication system(s)
• Experience using Customer Relationship Management (CRM) software; Salesforce is a plus.
• Experience working with large data and spreadsheets.
• Knowledge of medical terminology, CPT, ICD-10, and Revenue Codes
• Processing of Medical Claim Forms (HCFA, UB04)
• Knowledge of Medical Terminology
• Knowledge of HIPPA Guidelines regarding Protected Health Information
• Data Entry of Provider Claim/Billing information
• Experience handling or familiarity with Medical Claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Strong Analytical Skills
• Knowledgeable in MS Word and Excel

Benefits

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program
• Union Benefits for eligible titles
• Multiple employee discounts programs
• Commuter Benefits Programs