Claims Examiner - Xcelys Job at NTT DATA (Plano)

Job Responsibility

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims
Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
Plan and organize workload to ensure efficient and compliance resolution of issues
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to insure compliance
Warning reports are monitored daily to insure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455
Maintain minimum standards set for the department for quality and quantity of appeals received
Update Provider Dispute Database with the outcome resolution of issues as appeals are completed
Responsible for keeping Team Supervisor aware of potential problem issues for our education to all departments involved with claim issues. Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers
Any other assigned duties and delegated by the Management

Requirements

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims
Ability to interpret provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract. Including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers
Adjust claims, as appropriate, including calculation of interest and penalties due when applicable
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
Plan and organize workload to ensure efficient and compliance resolution of issues
Communicate to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department
Responsible for requesting special check run requests to insure compliance
Warning reports are monitored daily to insure compliance
Provider education calls completed based on outcomes of PDR
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455
Maintain minimum standards set for the department for quality and quantity of appeals received
Update Provider Dispute Database with the outcome resolution of issues as appeals are completed
Responsible for keeping Team Supervisor aware of potential problem issues for our education to all departments involved with claim issues. Advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers
Any other assigned duties and delegated by the Management

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Claims Examiner - Xcelys

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