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POST DATE 8/25/2016
END DATE 10/13/2016
Health Choice Integrated Care
JOB DESCRIPTIONHEALTH CHOICE INTEGRATED CARE, located in Flagstaff, Arizona manages behavioral health and primary care services in integrated care settings throughout Northern Arizona. We are committed to supporting a workforce enriched by diversity and multi-cultural values. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths then Health Choice Integrated Care is the place for you!
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
The Claims Specialist is responsible for processing claims for payment received from providers who contract with HCIC to provide healthcare services, and researching and resolving complex issues or problems relating to claims management. Responsibilities include: reviewing claims for completeness, accuracy and timeliness and processing claims into the claims system for payment, monitoring the claims processing system in accordance with HCIC and state policies and procedures to ensure accurate and timely processes and adjudications; researching and resolving complex problems relating to claims; and providing technical assistance or training to providers and staff regarding healthcare claims payment process and/or issues.
1. Processes medical claims from HCIC providers for payment including reviewing claims to ensure completeness, accuracy and timeliness and entering into the claim processing system; adjudicates claims (paper and electronic) in accordance with AHCCCS/ ADHS and HCIC guidelines, policies and procedures; validates and moves electronic 837 files into claiming system for processing; monitors and tracks all faileddenied files and notifies providers of the details of failed/denied files; and maintains claims files, including claims records and supporting documentation in accordance with HCIC standards.
2. Researches adjudication reports prior to finalizing each adjudication run to ensure claims are processing accurately against system and custom edits; researches and resolves claims not processing cleanly.
3. Prepares claims payment lists and Explanation of Benefits (EOBs), reconciles payment lists and Explanation of Benefits (EOBs) for all claims processed, and provides sends them to Providers in a timely manner.
4. Researches and responds to provider s questions relating to claim processing; researches and resolves ADHS/AHCCCS pends and Denial encounter errors; resolves complex problems and/or issues; troubleshoots inconsistent claims data between multiple claims processing systems (AHCCCS, DBHS, HCIC and Provider) to resolve conflicts using prescribed processes; and refers provider issues to other HCIC staff for further follow-up (MIS, Network, Care Management, Grievance and Appeals, Data Validation, Corporate Compliance and other staff), as appropriate.
5. Prepares reports and deliverables related to original submissions and resubmissions of claims and encounters, check registers, and claim/encounter errors; and researches and prepares responses to ADHS/AHCCCS audits and reviews relating to claiming system.
6. Participates in special projects or initiatives such as configuring and testing the QNXT claims system for new or revised system configuration, change packs and upgrades; and assisting with developing strategies to respond to new coding regulations.
7. Assists with updates to the HCIC internal claims procedure manual, and assists preparing for and conducting annual Provider Claims Training; trains new staff on claiming system, data entry and claims help desk.
8. Performs other duties of a similar nature and level as assigned
High School diploma or GED and four years claiming/billing experience; or an equivalent combination of education an experience, or equivalent experience sufficient to successfully perform the essential duties of the job.
Current knowledge of CMS 1500 / UB04 formats, HIPAA National Standards, 835/837 transactions, CPT procedural and HCPCS codes and ICD 9 / ICD 10 diagnosis coding.
Strong customer service skills.
Strong and current computer application proficiency.
Ability to follow oral and written instructions.
Strong attention to detail and high-level accuracy.
Primary Location: Arizona-Flagstaff
Organization: Health Choice Integrated Care
Education Level: High School Diploma/GED
Employee Status: Full Time Benefit Eligible 36-40 hrs/wk
Work Schedule: Days