Address
Form of work
Salary***Only candidates that reside in the Eastern or Central US Time Zones will be considered***
Title:
From: Medical Claims Management Specialist
FLSA Status:
Non-exempt
Shift: 8:30 am to 5:00 pm
Monday through Friday
Reports to: VP, Claims
Department:Claims
Employment Status: Full time
Supervisory Responsibilities:
No
Date Created/Last Evaluated:
01/30/2024
Summary
This position prepares medical disclosure statements, monitors ongoing ICD-10 diagnoses and notifies excess loss carriers of potential expenses. Works with vendors to make sure necessary information gets to claims department, Sales &Service department and excess loss carriers. This is a high-paced position that requires advanced skills in prioritizing and organizing workflow during the day.
Qualification Requirements
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Minimum Qualifications
- 2-4 year’s post-secondary education in health care management or medical field
- 4 or more years related experience may be considered in lieu of degree
- Certificate or demonstrated advance knowledge in ICD-10 coding and/or medical terminology
Knowledge, Skills and Abilities
- Proficiency with Microsoft Word, Excel and PowerPoint
- Accept responsibility and account for his/her actions
- Effectively present information publicly
- Organize and direct projects to completion
- Utilize time to organize and complete work within given deadlines
- Grasp and understand business concepts and issues
- Ability to look beyond the standard solutions
- Use sound thinking and reasoning to solve a problem
- Take care of the customers’ needs while following company procedures
- Ability to make decisions or take actions to solve a problem or reach a goal
Essential Functions
- Monitors ongoing trigger ICD-10 diagnoses and, based on preset standards, makes notification to excess loss carriers
- Monitors inpatient hospital admissions and case management files and, based on preset standards, make notification to excess loss carriers
- Prepares medical disclosure statements as indicated by client’s Plan renewal date and Sales & Service Department requests
- Updates, compiles and coordinates information related to medical disclosure statements as needed
- Serves as transplant coordinator for the area
- Liaison between Zelis and ACS. This encompasses claims edits, appeals, reconciliations and questions
- Manages work flow of case management and pre-certification activities and system changes and testing with this vendor
- Monitors UR/CM vendors’ sites, runs reports, primary contact for questions and performs referrals for case management.
- Liaison between Medical Management vendors that clients maintain for additional cost savings
- Produces Potential Large Claim notices to the Stop Loss carrier, ACS Stop Loss department, Account Manager and team
- Backup other members of the department when necessary
- Work closely with claims examiners and customer support on precertification/benefit questions
