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Job details
Job Type
Full-time
Full Job Description
We enjoy the important work we do every day on behalf of our members.
Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
Job Summary
The Complex Claims Processor II is responsible for the timely and accurate processing of claim inventory as assigned by the Complex Claims Supervisor. Using analytical and problem solving skills, the Complex Claims Processor II is expected to fully research and resolve all complex issues and problem codes for each claim. Additionally, the Complex Claims Processor II may be assigned to work on claims processing and reporting for specific projects and for member reimbursements.
Job Description
Process complex claims as assigned by supervisor:
- 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 a primary or secondary payer through the appropriate coordination of benefits
- Determine member’s eligibility if in question.
- Check to determine if services rendered on the claim are allowable under the member’s benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
- Manually calculate and/or apply pricing to each claim when necessary
- May assist partner departments by providing support on complex claims issues
- Review and update product and/or inventory specific reports as assigned by the 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
Additional specialized tasks:
- Provide subject matter expertise for Audit, departmental inquiries and other operational committees.
- 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
- 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 as assigned by supervisor
- Contribute to team and departmental standards for quality and production
- Participate in identifying opportunities for overall process improvements
Other:
- Serve as SME for documentation and testing
- Act as a role model and mentor to core/complex claims processors
- Participate in initiatives or provide backup support to other areas of department as requested
- 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: 24-48 months of 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 as HRP,Monument Xpress, Macess, CCMS preferred. Understanding of managed care concepts and a strong understanding of CPT, ICD-9 (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. Advanced verbal and written skills to communicate internally and externally. Working knowledge of Microsoft Office applications and internet navigation is preferred.
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.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.
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!
Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
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