Claims/Benefits Specialist

We are searching for a Claims Benefits Specialist — someone who works well in a fast-paced setting. In this position, you will investigate and accurately process claim appeals within the regulatory requirements mandated by the State of Texas. 

 
Think you’ve got what it takes? 

Job Duties & Responsibilities 
•    Process Specialists Adjustments, Replacements, Refunds, and Appeals Queues, Group queues content at 98% average, within 30 days of receipt 
•    Review and process pended claims, within 5 days of initial review 
•    Respond to internal inquiries within 48 hours of receipt. Review, investigate and provide accurate and efficient follow-up 
•    Ensure Special Projects are completed accurately, in a timely and efficient manner 
•    Participates in system testing and reviews for upgrades/implementation 
•    Identify and communicate to team, leadership, and other departments (if applicable), trends related to appeals processing, not yet addressed in a desk level procedure or identified by another team member 
•    Collaborate with Provider Relations team to educate providers regarding trends identified in appeals process 
•    Analyze potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow 
•    Investigate and research Texas Medicaid regulatory requirements for various payment methodologies for hospitals, physicians, home health agencies, CORFs, etc., to apply to various claim scenarios where system cannot be automated 
•    Utilize expertise with federal NCCI edits, MUE edits, etc., to determine if providers are billing inappropriately or fraudulently 
•    Refer potential fraud activity to FWA unit for further investigation 
•    Evaluate the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding. Refers trends of inappropriate activity for further data analytics for potential fraud 
•    Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing. 
•    Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt 

Skills & Requirements 
•    HS Diploma Or GED Required 
•    3 Years Claims Processing Experience Required 
      •    A Bachelor’s degree may substitute for the required experience