• Amerihealth Caritas Health Plan
  • $67,900.00 -111,780.00/year*
  • Philadelphia , PA
  • Telecommuting/Work-At-Home
  • Full-Time
  • 1103 Market St

Responsible for research and analysis related to provider claims issues. Identifying systematic and procedural issues resulting in claims processing errors and initiating action to resolve those issues. Responsible for ensuring the Plan stays in compliance with provider contracts. Perform statistical analysis, develop provider educational materials, and identify opportunities for quality improvement via claims management and contracting process.

Principal Accountabilities:

* Responsible for the gathering. production of and analysis of complex statistical data to identify financial and non-financial impacts and potential process and system improvements.

* Research State Rules and Regulations, surrounding the CMS Programs and ensures Facets is configured accurately to include State Fee schedules, GME, DRG changes.

* Monitors and reviews high profile/complex configuration implementations at management's discretion.

* Obtains and requests queries to identify root causes of claim denials, incorrect payments and claims that are not correctly submitted for payment. Provides feedback to Research Analysts I and Account Executives, management and corporate staff relative to error trending and resolution.

* Acts as the resource to other departments by developing and managing work plans which document the status of key relationship issues and action items for high profile providers.

* Monitors and reports financial impact for multifaceted recovery initiatives

* Participates with Corporate Operations Team to provide research and resolution to issues.

* Collaborates with Medical Management, Provider Network Management and Configuration to ensure that the following updates to Facets occur accurately and within established timeframes: Monthly MA Fee Schedule Updates, state policy changes, Annual and Quarterly HCPC's, CPT4 and ICD9/10 code updates, and NCCI updates. Communicates updates and impact of changes to internal stakeholders as appropriate.

* Maintains tracking system of operational issues, progress and status to ensure that issues are resolved within established timeframes and escalates open issues as needed when they exceed established timeframes.

* Assists with the implementation of department projects including contributing to the project and objectives, coordinating and monitoring the applicable processes and assisting with resolving the need for addition and/or changes in resources and tools.

* Serves as the Subject Matter Expert with the development of provider educational materials regarding coding and the submission of claims.

* Participates with other team members (i.e. Account Executives) with regards to provider education including face-to-face visits.

* Responsible for intensive research and analysis in order to complete work requests to submit to BPO for configuration changes.

* Serve as the lead role on committees such as The High Dollar Review Team, UAT, Encounters, and other operational teams as a source of education and insight of the claims payment process. Additionally, conducts research to identify and resolve root causes/critical edit rejections.

* Provides all documentation necessary to Network Management on the status and progress of identified provider configuration and workflow issues.

* Responsible to create/revise/change policies and procedures as well as Business Decision Documents as needed.

* Maintains excellent knowledge of provider contracts, plan policies and coverage's, claims processing guidelines and systems, and an overall understanding of operational workflows and processes.

* Accurately identifies and communicates claim issues to PCSU for adjustments to claims processed in error through EXP.

* Documents and Coordinates Issue Resolution for iHealth. Facilitates issue resolution by engaging appropriate resources at Health Plan or iHealth to act upon requests for data or make changes to existing process

* Audits Networks Operations staff for compliance with policy, timeliness and accuracy.

* Performs other related duties and projects as assigned.

* Adheres to AMFC policies and procedures.

* Key Competencies/Success Factors:

* Superior knowledge of national code sets and edits used in the Healthcare Industry.

* Possesses in-depth expertise in data analysis and data mining.

* Ability to perform impact analysis and make timely recommendations for issue resolution.

* Ability to assess department's needs and opportunities for improvement.

* Ability to manage multiple projects concurrently.

* Excellent analytical, organizational and research skills.

* Demonstrated interpersonal, oral and written communication skills.

* In-depth proficiency with office software applications (e.g., Microsoft Office Suite of products) as well as Crystal Reports and BI-Query.

NOTE TO APPLICANTS: This can be an in-office position in Philadelphia, PA or be a home based teleworker from a candidate residing in the Eastern Time Zone.


* Bachelor's Degree.

* B.S./B.A. preferred with emphasis in health services administration, information systems, or equivalent experience in medical office administration and/or claims administration, especially Medicaid billing.

* 1-2 years managed care or related experience.

* Minimum of 5 years of claims analysis experience in a Healthcare environment.

* Quality Improvement or Reporting experience preferred.

* Experience in the use of data measurement and analysis tools such as Control Charts, Pareto Charts, FEMA, Cause and Effect Diagrams and Time Series Plots (Run Charts) preferred.

* 1-2 years of Medicaid experience preferred.

* Certified Professional Coder (CPC) preferred.

* Certified Coding Associate from American Health Information Management (AHIM) preferred.

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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