Medicare Claims Analyst
Location: Pearland Administrative Office
Department: KS Plan Advantage-Claims
Job Type: Full Time
Kelsey-Seybold Clinic. Your Doctors for Life.
Kelsey-Seybold Clinic is Houston’s premier multispecialty group practice, founded in 1949 by Dr. Mavis Kelsey. With 19 clinic locations and more than 400 physicians, Kelsey-Seybold provides medical care in 55 medical specialties and is home to a nationally accredited Breast Diagnostic Center, Endoscopy Center, Infusion Center and Cancer Center. 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: Apply knowledge of Centers for Medicare & Medicaid Services (CMS) rules specific to DRG pricing methods, APC, 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 and other pricing tools and apply applicable reimbursement outcomes claims. Conduct pre/post analysis of high dollar claims and present summary to management.
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
Associates Degree or 2 years Claims Payment Analyst experience in lieu of education.
Experience with Microsoft products (word and excel.)
3 years of Facility Claims Adjudication experience in a HMO,PPO, or TPA environment.
5 years’ experience as Claims Payment Analyst and demonstrated ability to process complex professional and facility claims.
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.
Self-directed and able to absorb new material quickly