Senior Claims Analyst (Remote)
At Modis, we use our insight, knowledge, and global resources to make exceptional connections every day.
With 60 branch offices located strategically throughout North America, we are positioned perfectly to deliver the industry's top talent to each of our clients.
Clients choose Modis as their workforce partner to solve staffing challenges that range from locating hard-to-find niche talent to completing quick-fill demands.
Position:
Sr Analyst, ClaimsType:
ContractRate:
DOELocation:
REMOTEMUST-HAVES:
8 plus years of experience in a claims processing department at the professional level.
Medical billing/coding (ICD-9 and ICD-10); COB/TPL regulations and guidelines.
Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC).
requires knowledge of health plan division of financial responsibility (DOFR), and industry best practices.
Experience with anesthesia claims.
Position
Summary:
Under the direction of the Claims Supervisor, the Senior Analyst III, Claims, responds to escalated provider inquiries related to claim submissions and processed claims.
Coordinates with Outsourced Claims staff and company to resolve complex provider claims issues.
Responsible for identifying root cause errors and communication of trends, and contributing to ongoing Claims policy development.
Assists Provider Relations in Provider Education efforts related to Claims issues.
Essential Functions:
Serves as Claims expert in researching complex claims issues escalated from outsourced Call Center or from company Provider Relations, in accordance with established Provider Inquiry triage procedures (including Call Center, Provider Relations, and other escalated calls).
Researches claims issues in coordination with designated outsourced Claims leadership in accordance with company policies and procedures, Medi-Cal requirements, and industry standards for Claims adjudication.
Assists outsourced Claims department in determining proper courses of action in resolution of Provider claims issues.
Assures timely and accurate resolution of claims issues jointly with outsourced Claims and/or internal configuration staff.
Performs follow-up as necessary to meet commitments.
Assists in prioritization of provider claim research projects recognizing compliance and business priorities.
Initiates direct communication with providers when additional information is required and provides timely updates on progress or delays.
Communicates with providers on resolution and closure of issues, as needed.
Participates in meetings established to coordinate and track provider complaints.
Communicate to leadership all roots because errors to assure corrective actions are taken to prevent future problems.
Assures resolutions are in compliance with all regulatory and contractual requirements.
Remains abreast of Provider Dispute Resolution/Provider Grievance policies and coordinates closely with accountable staff and relevant policies.
Tracks remediation activities to resolve provider inquiry issues.
Assists in auditing claim history for recoveries and adjustments for like claims.
Participates in Provider Education efforts as appropriate.
Represents Claims in meetings with providers.
A cents EUR cents Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes, and adjustments.
Identifies and communicates deficient processing trends and coordinates with outside vendors and internal management to develop appropriate process corrections.
Position QualificationsAnalytical Skills - Ability to use thinking and reasoning to solve a problem.
Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.
Technical Aptitude - Ability to comprehend complex technical topics and specialized information.
Financial Aptitude - Ability to understand and explain economic and accounting information, prepare and manage budgets, and make sound long-term investment decisions.
A cents EUR cents Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
Experience:
8 plus years of experience in a claims processing department at the professional level.
Prior experience as a senior analyst/examiner in a lead capacity preferred.
Medi-Cal/Medicaid managed care experience strongly desired.
Advanced computer skills included in the MS Office products.
Knowledge of:
Principles and practices of health care service delivery and managed care, Medi-Cal eligibility and benefits.
Medical billing/coding (ICD-9 and ICD-10); COB/TPL regulations and guidelines.
State and federal regulations as they relate to managed care, Medicaid and other related business and policies governing managed care issues.
All claim types and standard claims adjudication practices.
Provider reimbursement methodologies.
Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC).
Also requires knowledge of health plan division of financial responsibility (DOFR), and industry best practices.
Interested candidates, please send your resume to yangini.
kapoor@This role is not open for C2C.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
With 60 branch offices located strategically throughout North America, we are positioned perfectly to deliver the industry's top talent to each of our clients.
Clients choose Modis as their workforce partner to solve staffing challenges that range from locating hard-to-find niche talent to completing quick-fill demands.
Position:
Sr Analyst, ClaimsType:
ContractRate:
DOELocation:
REMOTEMUST-HAVES:
8 plus years of experience in a claims processing department at the professional level.
Medical billing/coding (ICD-9 and ICD-10); COB/TPL regulations and guidelines.
Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC).
requires knowledge of health plan division of financial responsibility (DOFR), and industry best practices.
Experience with anesthesia claims.
Position
Summary:
Under the direction of the Claims Supervisor, the Senior Analyst III, Claims, responds to escalated provider inquiries related to claim submissions and processed claims.
Coordinates with Outsourced Claims staff and company to resolve complex provider claims issues.
Responsible for identifying root cause errors and communication of trends, and contributing to ongoing Claims policy development.
Assists Provider Relations in Provider Education efforts related to Claims issues.
Essential Functions:
Serves as Claims expert in researching complex claims issues escalated from outsourced Call Center or from company Provider Relations, in accordance with established Provider Inquiry triage procedures (including Call Center, Provider Relations, and other escalated calls).
Researches claims issues in coordination with designated outsourced Claims leadership in accordance with company policies and procedures, Medi-Cal requirements, and industry standards for Claims adjudication.
Assists outsourced Claims department in determining proper courses of action in resolution of Provider claims issues.
Assures timely and accurate resolution of claims issues jointly with outsourced Claims and/or internal configuration staff.
Performs follow-up as necessary to meet commitments.
Assists in prioritization of provider claim research projects recognizing compliance and business priorities.
Initiates direct communication with providers when additional information is required and provides timely updates on progress or delays.
Communicates with providers on resolution and closure of issues, as needed.
Participates in meetings established to coordinate and track provider complaints.
Communicate to leadership all roots because errors to assure corrective actions are taken to prevent future problems.
Assures resolutions are in compliance with all regulatory and contractual requirements.
Remains abreast of Provider Dispute Resolution/Provider Grievance policies and coordinates closely with accountable staff and relevant policies.
Tracks remediation activities to resolve provider inquiry issues.
Assists in auditing claim history for recoveries and adjustments for like claims.
Participates in Provider Education efforts as appropriate.
Represents Claims in meetings with providers.
A cents EUR cents Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes, and adjustments.
Identifies and communicates deficient processing trends and coordinates with outside vendors and internal management to develop appropriate process corrections.
Position QualificationsAnalytical Skills - Ability to use thinking and reasoning to solve a problem.
Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.
Technical Aptitude - Ability to comprehend complex technical topics and specialized information.
Financial Aptitude - Ability to understand and explain economic and accounting information, prepare and manage budgets, and make sound long-term investment decisions.
A cents EUR cents Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
Experience:
8 plus years of experience in a claims processing department at the professional level.
Prior experience as a senior analyst/examiner in a lead capacity preferred.
Medi-Cal/Medicaid managed care experience strongly desired.
Advanced computer skills included in the MS Office products.
Knowledge of:
Principles and practices of health care service delivery and managed care, Medi-Cal eligibility and benefits.
Medical billing/coding (ICD-9 and ICD-10); COB/TPL regulations and guidelines.
State and federal regulations as they relate to managed care, Medicaid and other related business and policies governing managed care issues.
All claim types and standard claims adjudication practices.
Provider reimbursement methodologies.
Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC).
Also requires knowledge of health plan division of financial responsibility (DOFR), and industry best practices.
Interested candidates, please send your resume to yangini.
kapoor@This role is not open for C2C.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
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