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Complex Claims Processor at Tufts Health Plan in Watertown, Massachusetts

Posted in Other 30+ days ago.





Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

The Complex Claims Processor is responsible for the timely review, adjudication and follow-up of medical claims as assigned by the Complex Claims Supervisor. Using analytical and problem solving skills, the Complex Claims Processor is expected to fully research and resolve all complex issues and problem codes for each claim. Additionally, the Complex Claims Processor may be assigned to work on claims processing and reporting for specific projects and for member reimbursements. Determines insurance coverage, examines and resolves complex claim issues, documents actions and ensures legal compliance. Will adapt to change, is open to new ideas, takes on new responsibilities, handles pressure and adjusts plans to meet changing needs.

Job Description

Process complex claims as assigned by supervisor:


  • Follow all documented processes for Review and Repair of claims holding for adjudication

  • Fully research and resolve all complex issues and problem codes so claim can properly adjudicate

  • Manually apply specific product benefit rules to claim for adjudication

  • Ensure claim payment is updated to correctly reflect Tufts Health Plan's status as primary or secondary payer through the appropriate coordination of benefits

  • Determine member's eligibility if in question.

  • Ensure the proper authorization and referrals were obtained as required by the plan.

  • Validate Pricing methodology against contract terms as necessary

  • May assist partner departments by providing support on complex claims issues

  • Review and update product and/or inventory specific reports as assigned by supervisor

  • Communicate (verbally or written) with members and providers to answer and resolve questions

  • Monitor pending claims daily and ensure claims are released timely for adjudication

  • Work with the Fraud, Prevention & Recovery Unit and Customer Relations to ensure timely and accurate processing of Member Reimbursements

  • Coordinate all aspects of claims processing related to COB/TPL functions including the maintenance and updating of COB and TPL policies and procedures.

  • Research liens related to Worker's Compensation and Subrogation as well as research of TPL and COB claims related to Cost Avoidance and Claim Recoveries.

  • Ensure that policies and procedures continue to adhere to state requirements so that the existing COB/TPL program remains comprehensive.

Make recommendations and implement approved actions as policies and regulatory items change.

Additional specialized tasks:


  • Provide support for Audit, departmental inquiries and other operational committees.

  • May represent the Department in meetings, with both internal and external customers, in a professional manner.

  • Process member reimbursement requests, working with the Fraud, Prevention & Recovery Unit and Customer Relations, to ensure timely and accurate results.

  • Ensure compliance with all legal/regulatory requirements applicable to specific product or employer group specifications

  • Become familiar with both Government and Commercial payers for claim processing requirements

Analyze, trend and reconcile inventory variances between vendors, company alliances, employer groups and Tufts Health Plan.

Quality & Production:


  • Achieve individual standards for quality and production , meeting the goals consistently each month

  • Adhere to all Workforce Management tasks as assigned

  • Contribute to team and departmental standards for quality and production

  • Participate in identifying opportunities for overall process improvements

Identify documentation updates needed or changes in workflow in order to promote department

Other:


  • Serve as a resource for documentation and testing

  • Participate in initiatives or provide back up support to other areas of department as requested

  • Understand company mission/values, keep job knowledge current; be in command of critical issues

  • Correspond well, both verbally and in writing, as well as display good listening skills

  • Share information and ideas with others

  • Be able to work under stress and meet deadlines

  • Participate in staff & individual meetings and training sessions as required

Comply with all department and company guidelines and policies

Requirements

EDUCATION: Associates degree or equivalent business experience in a claims/customer service healthcare environment preferred.

EXPERIENCE: 18-24 months experience as a Tufts Health Plan Complex Claims Processor or similar claims processing or customer service experience required

SKILL REQUIREMENTS: Experience with Tufts Health Plan's internal applications, such HealthRules Payor, Macess, CCMS or MedHok preferred. Understanding of managed care concepts and a strong understanding of CPT, ICD-10, HCPCS coding guidelines and CMS1500 & UB04 billing forms preferred. Position requires strong problem solving and analytical skills with the ability to multi-task. Must be able to work independently and as a part of a team. Good verbal and written skills to communicate internally and externally. Working knowledge of Microsoft Office applications and internet navigation is required.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: Overtime may be required during peak volume periods as requested by management. Requires ability to use personal computer, sitting for extended periods of time.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!


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