Medicare Claims Analyst
Location: Pearland Administrative Office
Job Type: Full-Time
Department: KS Plan Advantage
Kelsey-Seybold Clinic. Your Doctors for Life.
Since 1949, Kelsey-Seybold Clinic has served its patients with one goal in mind – combine the expertise of physicians in a variety of medical specialties, with the close personal care of a family doctor. Kelsey-Seybold is Houston’s largest community-based physician group, caring for more than 400,000 patients. With 19 clinic locations, we are growing to meet the health care needs of our diverse patient population. Our mission is to provide our team members with exceptional opportunities for professional and personal growth.
Responsible for the adjudication of complex facility claims including hospital, durable medical equipment, home health services, skilled nursing facilities as well as associated professional claims. Essential job functions include: Performance of DRG pricing methods, Outpatient Prospective payment system mechanics (OPPS) and Contractual Payment Rates. Position will work closely with Supervisor and Claim Services to complete request for claims adjustments via CRM Module. Review and interpret provider issues and member reimbursement requests. Utilize DRG Grouper Product and apply recommendations to applicable claim. Conduct pre/post analysis of high dollar claims and present summary to management.
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
A. Associates Degree or 2 years Claims Payment Analyst experience in lieu of education.
B. Experience with Microsoft products (word and excel.)
A. 3 years of Facility Claims Adjudication experience in a HMO,PPO, or TPA environment.
B. 5 years’ experience as Claims Payment Analyst and demonstrated ability to process complex professional and facility claims.
A. Demonstrated understanding of DRG pricing methods, Outpatient Prospective Payment System Mechanics, Outliers and Case Rate Payment Mechanics. Knowledge of CMS rules and regulations. Skillful in medical terminology, CPT and ICD9 Coding and billing. Demonstrate strong working knowledge of Payor Contracts, Utilization Review procedures (specific to authorizations). Able to interpret and apply contracts, fee schedules and reimbursement methods. Ability to understand and/or interpret regulatory guidelines (i.e. TDI, CMS, HIPAA, etc.) Strong knowledge of Claims Services and Claim Review Processes.
A. Self-directed and able to absorb new material quickly