Health Benefits Appeals Analyst Job Listing at MedStar Health in Columbia, MD (Job ID 156147)

Description

About the Job

General Summary of Position
Regularly communicates with both internal and external customers concerning benefit and fee schedule interpretation NCCI (National Correct Coding Initiative) and other claims issues. Researches incoming appeals and determines final resolution based on health plan policies and procedures. Uses knowledge of Medicaid rules and regulations claims appeals and managed care to explain procedures to vendors providers and customers. Acts as a resource for claims customer service provider relations and other departments.

Primary Duties and Responsibilities

• Researches and analyzes health plan benefits fee schedules and payment policies to determine how to decision provider requests.
• Reviews claims appeals provides communication to providers keeps accurate and complete claims appeal records. Researches and resolves billing and payment issues.
• Assists in implementing and maintaining administrative claims appeal policies procedures and appeal infrastructure.
• Coordinates the review and processing of provider claim appeals. Evaluates and investigates claim appeals by reviewing plan benefit documentation payment and reimbursement policies.
• Generates appeal acknowledgment letters and resolution letters per Maryland Department of Health (MDH) / District of Columbia regulations.
• Ensures that providers have submitted appeal request timely.
• Tracks all inquiries or complaints to ensure that cases are resolved within State-required timeframes. Documents resolution and prepares and sends written correspondence in response to members initiating complaints within State / NCQA required timeframes.
• Maintains established daily performance benchmarks and meets the established productivity standard for the department.

Minimal Qualifications
Education

• Associate degree in Healthcare Administration, Business Administration or related field required 
• Bachelor's degree in Healthcare Administration, Business Administration or related field preferred
• One year of relevant education may be substituted for one year of required work experience.

Experience

• 5-7 years Experience in the health care delivery system or insurance setting required 
• Experience with managed care/claims appeals experience including experience with insurance/managed care benefits and procedures for appeals and claims processing required
• One year of relevant professional-level work experience may be substituted for one year of required education.

Licenses and Certifications

• Certified Professional Coder (CPC) preferred 
• Claims Appeals certification preferred

Knowledge Skills and Abilities

• Knowledge of all aspects of claims processing auditing coding A/R and reporting (MicroSoft Excel and Access).
• Excellent verbal and written communication skills.
• Data mining and analytical skills.
• Ability to recognize analyze and solve a variety of problems.