Managed Care Claims Analyst
Location: Pearland Administrative Office
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 medical/dental claims while maintaining productivity and accuracy standards. Essential job functions include: application of various payment methodologies including but not limited to: case rates, RBRVS Fee Schedules, Usual and Customary rates as well as Contractual rate; including LOAs. Analyst must initiate internal documentation via Customer Relationship Module (CRM) to various departments within Managed Care as it pertains to Contracts, Eligibility, and Member Benefits. Perform departmental research necessary to effectively adjudicate claim payment. Essential job function includes the ability to interpret provider contracts and apply to claim payment.
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
High School Diploma or equivalent
1 year of college experience
5 years of claims adjudication experience in a HMO, PPO, or TPA environment or 6 months of Managed Care preprocessing experience.
6 months experience claims adjudication experience with KSC; and demonstrated ability to process complex medical claims.
Demonstrated understanding of medical terminology, CPT and ICD 9 and ICD 10 Codes, payment rates including RBRVS, Usual and Customary, L.O.A.s and Contractual agreements.
Demonstrate strong working knowledge of industry standards regarding c.p.t.
coding, coordination of benefits, hcpcs and Medicare reimbursement guidelines.
Demonstrated knowledge of health plan benefits and financial obligation summary interpretation.
Knowledge of primary payor’s explanation of benefit; with ability to apply secondary payment
Knowledge and interpretation of letters of agreements and plan’s financial obligation summary.
Able to interpret and apply contractual rates to claims adjudications, fee schedules and reimbursement methods.
Self directed and able to absorb new material quickly