Claims Adjustment Specialist I

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

As a Claims Adjustment Specialist I, this individual will be responsible for analyzing standard to complex post-paid healthcare claims that require in depth research to determine accuracy and mitigate payment errors. The Claims Adjustment Specialist I will also be responsible for adjusting medical claims that result in overpayment or underpayment due to claim processing system issues, contract amendments, processing errors, or other issues. This position will be responsible for responding to inquiries from providers whose claims may be paid incorrectly and performing accurate data entry and maintenance accurate records and files.

• Research and analyze medical claims adjustment requests along with related documentation to determine payment accuracy and adjust/adjudicate as needed using multiple systems and platforms.
• Ensure that the proper payment guidelines are applied to each claim by using the appropriate tools, processes, and procedures (e.g., claims processing P&P’s, grievance procedures, state mandates, CMS/Medicare/Medicaid guidelines, benefit plans, etc.)
• Research claims that may have paid incorrectly and communicate findings for adjustment; Adjust claims based on findings (i.e., correct coding, rates of reimbursement, authorizations,
  contracted amounts etc.) ensuring that all relevant information is considered.
• Advise business partners of findings outcome if their input is needed to help fix the issue.
• Communicate through correspondence with providers regarding claim payment or additional required information in a clear and concise manner.
• Process the adjustment of claims in a timely manner, according to established timelines.
• Remain current with changes/updates in claims processing, as well as updates to coding systems.
• Maintain accurate records of all claims processed, including notes on actions taken.
• Generate reports on claim activity as requested.
• Respond to audits of claims processed.
• Able to work independently and exercise good judgment

• High School Degree or evidence of having passed a High School Equivalency Program required. Associate degree preferred.
• Minimum 3 years of claims operations experience in a healthcare field, with knowledge of integrated claims processing required.
• Experience using a PC and claim adjudication system(s)
•  Experience using Customer Relationship Management (CRM) software; Salesforce is a plus.
• Experience working with large data and spreadsheets.
• Knowledge of medical terminology, CPT, ICD-10, and Revenue Codes
• Processing of Medical Claim Forms (HCFA, UB04)
• Knowledge of Medical Terminology
• Knowledge of HIPPA Guidelines regarding Protected Health Information
• Data Entry of Provider Claim/Billing information
• Experience handling or familiarity with Medical Claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Strong Analytical Skills
• Knowledgeable in MS Word and Excel

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