Claims Department Lead / Technical Claims Specialist

REPORTS TO

Assistant Manager, Claims & Appeals

JOB SUMMARY

The primary function of this job is to advise and to provide technical support to the Department Manager and other staff concerning medical claims procedures and research, especially in regard to departmental procedures for determining which services are covered medical expenses and related guidelines, reviews and appeals.

CONTACTS AND RELATIONSHIPS

This position interacts with the Health Plan staff, Plan participants, business managers, health care providers, medical insurance companies and related governmental agencies, and medical consultants.

ESSENTIAL FUNCTIONS

Work independently using discretion and independent judgment under the general supervision of the department managers and within broad parameters of policy established by management:

• Advise management on medical claims issues and in developing department policy guidelines for use by the examiners and PSD.
• Recommend changes to management on Health Plan language for medical benefits.
• Identify issues and related questions for claims or appeals that require physician review by Blue Cross or by other medical consultants.
• Provide guidance and expertise to claims examiners on claims questions and problem claims.
• Assist claims examiners with difficult Anthem Blue Cross professional pricing and with AWP pricing for non-network infused/injected drugs.
• Assist PSD with calls regarding medical claims issues and complex medical benefit inquiries, facilitating voluntary pre-reviews when requested and determining if case management may be appropriate for home health care.
• Evaluate and make recommendations regarding provider complaints regarding adjudication of professional benefits.
• Determine which procedure codes the claims system auto-adjudicates to deny as investigational/not medically necessary, and develop a system for maintaining records of the basis for denial of these codes.
• Liaison with the IT Department with claims system configuration, including testing, implementation and documentation. Advise management on findings and status.
• Liaison with the Benefits Analysis Department in review of claims data to ensure accurate reporting.

SKILLS AND ABILITIES

• Must have considerable knowledge of group health plan philosophy and Department of Labor health-claim regulations.
• Extensive knowledge of medical benefits, medical terminology and coding, and coordination of benefits rules.
• Considerable knowledge of basic math related to claims adjudication

EDUCATION AND EXPERIENCE

Seven or more years of group health claims processing at an advanced level, including extensive work in medical reviews and appeals and in writing/interpreting medical benefits language.

Pay Range - $70k - $80k per year.

*Onsite*

Alternative Workweek Eligible - 4/10, 9/80, 5/40