Medical Claims Specialist (Remote)

GENERAL STATEMENT OF JOB

Responsible for all accounting functions related to a designated area of physical and behavioral health medical claims processing to ensure that providers receive timely and accurate payment. This position is responsible for claims adjudication through continuous monitoring and quality control measures. Responsibilities include finalizing claims processed electronically for payment and reviewing claim adjudication results for both Title XIX and non-title XIX claims, payment, and denial patterns, ensuring adjudication accuracy in the claims processing system, adhering to policy and procedures, responding to provider inquiries and providing education/training to providers.

ESSENTIAL JOB FUNCTIONS

Claims Adjudication: This position will be responsible for finalizing claims processed for payment and maintain claims adjudication workflow, reconciliation and quality control measures to meet or exceed prompt payment guidelines. This position is responsible for reconciling provider claims payments through quality control measures, generally accepted accounting principles and Vaya's policies and procedures. This position will assess Title XIX and non-Title XIX claims adjustments for correction or recoupment and will coordinate the recoupment process to ensure payment is recovered for inappropriately paid claims.

Customer Service: This position will maintain provider satisfaction by being available during regular business hours to handle provider inquiries; interacting in a professional manner; providing information and assistance; and answering incoming calls. This position will assist providers in resolving problem claims and system training issues. This position will also serve as a resource for internal staff to resolve eligibility issues, authorization, overpayments, recoupment or other provider issues related to claims payment.

Compliance and Quality Assurance: This position reviews internal bulletins, forms, appropriate manuals and applicable revisions, and fee schedules to ensure compliance with established procedures and processes. Attend and participate in workshops and training sessions to improve technical competence.

Miscellaneous: Other duties as assigned, including coverage of specific functions of other staff to assist the Department as work demands may dictate.

KNOWLEDGE, SKILL & ABILITIES:

• Must maintain a working knowledge of the Medicaid Waiver requirements, HCPCS, revenue codes, ICD-9/10, CMS-1500/UB-04 coding, compliance and software requirements used to adjudicate physical and behavioral health medical claims.
• Ability to handle large volume of work and to manage a desk with multiple priorities.
• Ability to work in a team atmosphere and in cooperation with others and be accountable for results.
• Ability to maintain confidential information.
• Ability to establish appropriate and respectful relationships/partnerships with providers served. Ability to work with a multi-disciplinary team approach.
• Ability to enter routine and repetitive batches of data from variety of source documents within structured time schedules.
• Strong organization skills.
• Computer proficiency, including considerable knowledge of Word and Excel programs.
• Ability to speak and write professionally.
• Ability to read printed words and numbers rapidly and accurately.
• Ability to understand oral and written instructions.
• General knowledge of office procedures and methods.

QUALIFICATIONS & EDUCATION REQUIREMENTS

High school diploma or GED and 4 years of experience in healthcare processing medical claims/reimbursement with experience in Physical Health and/or Behavioral Health claims. Associate Degree in Business Administration, Accounting, Finance or related field preferred.

OR a combination of education and experience as follows:

Graduation from a four year college/university with a major in business administration, health administration, communications or a related field may be substituted for the required experience; or a two year degree in business administration, health administration, information systems, accounting or a related field from a community college may be substituted for three of the four years of experience.

PHYSICAL REQUIREMENTS:

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled.

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.