Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Medical Claims Review Analyst (remote)
Summary of Job
Support contract performance management of a large health system. Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines. Identify and analyze single issues and trends to determine root causes.
Provide recommendations for solutions to minimize errors and delays in systems and/or processes. Monitor system output to ensure proper functioning.
Responsibilities:
- Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
- Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
- Track issues and monitor trends to support their resolution.
- Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
- Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
- Conduct regular meetings with the assigned provider groups for status of AR files and recycles.
- Support departmental goals for cycle time by organizing and tracking claims for review.
- Monitor and provide timely responses for the designated provider group emails and AR files.
- Perform other related tasks as directed or required.
Qualifications:
- Bachelor’s Degree
- 2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment (Required)
- Additional experience/specialized training may be considered in lieu of educational requirements (Required)
- Strong knowledge of claim processing policies and procedures (Required)
- Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures (Required)
- Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) (Required)
- Ability to accurately interpret information from contractual and technical perspectives (Required)
- Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies (Required)
- Strong analytical and problem-solving skills (Required)
- Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines (Required)
- Ability to effectively absorb and communicate information (Required)
- Strong Interpersonal and teamwork skills (Required)
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.