Spclst, Accumlations Research

May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums:
https://(Use the "Apply for this Job" box below)..

Job Summary:

Under indirect supervision, responsible for accurate and complete research into member/family accumulation status. Complete comprehensive review of claims and encounters and/or pre-authorization data elements submitted on claims/bills/pre-authorization against data applied to the processing systems. Research at this level includes all lines of business.

Essential Responsibilities:

+ Review manual seeding of accumulation data into Tapestry for benefits administered by TPAs (Manually seed member and family accumulation data based on review of external TPA seeding analysis. Manually override and/or adjust claims based on review of external TPA seeding analysis.)

+ Create file audit query and review query results to determine historical accuracy of member/family accumulation (Adjust and/or seed corrected amounts into Tapestry accumulation deductible/maximum out of pocket/visit limit buckets. Create a file audit summary to be provided as explanation to Member and Provider.)

+ Research misrouted claims and/or seeding information to assign to the correct Tapestry accumulation bucket(s) and accumulation eligibility segments (Manually seed member & family accumulation data to properly route claims and/or seeding information to the appropriate Tapestry accumulation bucket(s). Manually adjust claims to correct member/family accumulation bucket(s).)

+ Review inquiries (e.g., CHATS/CRM/Escalated Accumulations Email Box) to ensure accurate eligibility, benefit configuration and Tapestry system integration (Create CRMs as needed to correct eligibility/benefit/systems integration issues. Monitor CRM status and escalate need for resolution. Adjust claims, as needed, upon resolution of issues.)

+ Research Member & Provider Grievances and provide information required to determine the grievance resolution (Ensure timely remediation of the root cause of Member/Provider grievance. Perform adjustments to claims to properly update member/family accumulation buckets based upon the Member/Provider grievance resolution action plan.)

+ Investigate and provide information required to support responses to the Department of Managed Healthcare (DMHC) and DOI requests for information (Ensure timely corrective actions based upon DMHC and DOI directives that result from the RFI process.)

+ Research member/family benefit information necessary to remediate TPA accumulation file errors (Adjust claims, as needed to correct TPA accumulation file errors. Notify TPAs (EMI & PBMs) of accumulation corrections that must be reflected in their data processing systems.)

+ Seeding as needed to support ancillary product lines (e.g., Dental and Medimpact; inter-regional seeding)

+ Other duties may be assigned within the department job functions.

Basic Qualifications:

Experience

+ Minimum five (5) years of medical claims in an integrated health plan environment adjudication experience (HMO, PPO, Indemnity environment). Which includes one (1) year of processing high complexity claims i.e. Coordination of benefits, transplant .and adjustments.

Education

+ High School Diploma or General Education Development (GED) required.

License, Certification, Registration

+ N/A

Additional Requirements:

+ Basic PC skills

+ Working knowledge of Microsoft Word

+ Ability to work in a in a Labor Management Partnership environment

+ Ability to understand and meet customer needs in a claim setting

+ Ability to apply procedures, practices and methods used in claims processing

+…