Senior Claims Adjuster

The Senior Claim Adjuster is responsible for assisting in the day to day managing of claim issues for high profile providers. This role acts as the single point of contact for their assigned accounts for any claim related issue. They are the liaison/advocate between the provider and internal departments. The Senior Claim Adjuster works directly with practice managers, via phone, email and in-person meetings on a regular basis to resolve outstanding claim issues. This role works with our Provider Contracting and Provider Relations departments to assist in managing the operational aspects of the provider relationship, and will attend internal meetings to present their research and findings on claims issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming inquiries regarding current claims and escalated issues. Collaborates in strategic planning for their assigned accounts. Works collaboratively with business and operational units to ensure prompt resolution of open issues. . They assume ownership and accountability for the timely and accurate identification and resolution of claims issues through thorough research using the necessary tools such as a review of provider contracts, benefits, JIRA tickets, CES edits, NCCI edits, correct coding, reporting, testing, and other appropriate tools.

Duties and Responsibilities:

Responsibilities include, but are not limited to:

• Serves as the SME and Lead on functional deliverables ensuring optimal efficiency in all areas of responsibility

• Tracks and maintains all known issues, including the operational provider issue logs, and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
• Conducts extensive research on complex payment inaccuracies and documents root cause analysis and mitigation
• Receives and responds timely to correspondence on escalated issues
• Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system.
• Request appropriate adjustment via AWD to the Claims BPO
• Represents Neighborhood to internal and external customers in a professional manner
• Attends ad-hoc and regularly scheduled operational meetings with provider community within and outside of the organization
• Responsible for documenting deliverables from meetings/calls and providing timely resolution of same.
• Collaborates with other departments to root cause and resolve claim payment issues. Opens JIRA tickets as needed.
• Provides support and guidance to all Claims teams on identified system issues
• Partners with the Documentation Specialist to create desktop procedures
• Supports testing of new functions, features, system upgrades and new implementations
• Other duties/special projects as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

• Associates degree or equivalent relevant work experience in lieu of a degree
• Minimum of five (5) years experience with a managed care organization or a health care related organization (HMO; Medicaid/Medicare)
• One (1) or more years experience working in direct relation with the provider community (claim resolution, GAU, provider relations, contracting, etc.)
• Strong understanding and experience in all aspects of claims adjudication, processing, and analysis.
• Ability to manage multiple projects simultaneously
• Demonstrated experience with managing and cultivating strong business relationships with the provider community
• Ability to understand business systems and articulate deficiencies and opportunities
• Understanding of provider reimbursement mechanisms
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
• Basic understanding of contract implementation and working knowledge of contract language
• Must exercise excellent judgment and be effective working autonomously and as part of a team
• Exceptional listening skills and verbal/written communication skills
• Problem solver with strong attention to detail
• Extensive knowledge of all Neighborhood products and services, including all key operations and their functions and a familiarity with Medical Management and any other internal department and external vendors.(internal candidate)
• Must be knowledgeable of resources available within the organization to resolve both internal and external problems and concerns.
• Strong information management skills including the ability to organize information, identify subtle and/or complex service delivery issues that impact customers and the ability to articulate and pursue solutions to problems impacting service
• Knowledge of HIPAA standards and CMS guidelines

Preferred:

• Bachelors degree
• Coding Certification from the American Academy of Professional Coder (AAPC) or American Health Information Management Association (AHIMA)
• Prior experience with JIRA issue tracking system or a similar project tracking system
• Experience with Optum Encoder or similar coding program/website
• Prior Network Management experience
• Project Management experience

Core Company-Wide Competencies:

• Communicate Effectively
• Respect Others & Value Diversity
• Analyze Issues & Solve Problems
• Drive for Customer Success
• Manage Performance, Productivity & Results
• Develop Flexibility & Achieve Change

Job Specific Competencies:

• Collaborate & Foster Teamwork
• Build Relationships & Cultivate Networks
• Attend to Detail & Improve Quality
• Exercise Sound Judgement & Decision Making

FDR Oversight: N/A

Flexible Work Arrangement:

• Yes

Telecommuting Arrangement:

• No

Travel Expectations:

• N/A

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.