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Revenue Specialist

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POST DATE 9/9/2016
END DATE 10/29/2016

Tufts Health Plan Watertown, MA

Watertown, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
Some College


Under the general supervision of the manager, the responsibilities for this position will primarily be the development and refinement of the analysis and reconciliation for member eligibility and payment records. Additionally, this position will ensure the accuracy of the beneficiary files and data submissions to/from CMS/State.

This individual regularly demonstrates personal resiliency in times of changing direction and consistently performs routine daily deliverables independently. He/She must be able to plan, organize, and prioritize work to ensure completion in a timely manner. Additionally, this individual will be expected to support the collaborative efforts within Membership Operations and outside the department. Also, he/she is expected to learn and understand department processes and their interdependencies, contribute to process enhancement opportunities, and support Medicare Preferred and departmental objectives.

* CMS and State revenue analysis, trending, and reporting
* Perform transactional tasks, including accurately entering and updating member and enrollment records.
* Perform operational analysis including reviewing data and information to draw conclusions regarding member transactional trending.
* Perform monthly reconciliation of both CMS & State data and payment variances.
* Support financial analysis process by providing error and trending reports in a timely manner.
* Support the development and refinement of the monthly analysis and reporting process for the following: LIS, ESRD, Hospice, Medicaid, State/county Code (SCC), Out of Area (OOA), etc.
* Expand knowledge of the monthly payments received by CMS and State.
* Maintain high compliance levels.
* Analyze reports (from applications & database), raise questions and research member discrepancies.
* Identify enhancement opportunities for databases and applications.
* Work with manager to develop metrics and exhibits.
* Ensure accuracy of Beneficiary data in THP, CMS and State systems
* Review/research data rejects.
* Analyze trends; provide reporting.
* Support root-cause analysis; propose process improvements.
* Collaborate on implementation of new process reporting.
* Adjust member records and set sequences in Diamond/Market Prominence -- Special Status Beneficiaries, TROOP, 4Rx, OOA, SCC, COB, MSP, etc.
* Update Notes/Comments in Diamond/Market Prominence, as required.
* Process notification letters. * Participate in monthly Medicare Secondary Payer (MSP) processes
* Resolve MSP payment and eligibility discrepancies appropriately and timely.
* Perform MSP file transfers & database updates.
* Support with operational tasks, as needed.
* Cross-train teammates on MSP processes.
* Research &/or create MSP documentation.
* Anticipate & express ways to efficiently recoup outstanding revenue from CMS.
* Provide input for routine or non-critical issue resolution
* Contribute to process enhancement opportunities; make proposals and recommendations.
* Ad-hoc projects, as necessary.
* Conduct in depth quality checking; identify QC training opportunities and trends .
* Create/format reports (worksheets, graphs, business documents).
* Delegate/share work within department to balance workload.

EDUCATION: (minimum education)
* Associates degree; some college preferred.

EXPERIENCE: (experience level required)
* 1-3 years related business experience; Medicaid and Medicare experience preferred.

SKILL REQUIREMENTS: (Include interpersonal skills)
* Significant MS Office skills, with focus on Excel and Access at an intermediate level.
* Solid communication skills (effective verbal and written skills).
* Strong organizational and time management skills.
* Send/receive email, use Lotus Notes calendar to manage daily activities.
* Use applications and business tools (PC, copier, fax machine).
* Demonstrate flexibility, commitment, and resiliency in times of business and organizational change.
* Demonstrate professional demeanor at all times.
* Support collaboration across Membership Operations and other departments and work cooperatively as a team member.
* Provide/accept constructive criticism for improvement, including peer and supervisor feedback for performance management. Coach others to do so.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime)

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Founded in 1979 as a non-profit health maintenance organization (HMO), Tufts Health Plan is one the country's largest HMO offering a full array of healthcare coverage options to individual consumers and employer groups. Tufts Health Plan has received high marks for its quality from a variety of third parties including U.S News & World Report and Newsweek.