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Job Details

Medicare Claims Specialist

Job Ref: 56350
Category: Claims
Department: CLAIMS
Location: 160 Water St. #3, New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $70,000.00
Salary Range: $70,000.00 - $80,000.00

Marketing Statement

MetroPlus Health Plan 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, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview 

Resource for claims and coding issues related to the Medicare products at MetroPlus Health Plan. Incumbent will provide decision support, claims compliance auditing and analysis related to claims payment. Perform review of system benefit configuration, and CMS compliance requirements. Provides decision, research and analysis support to the DST BPO and MetroPlus Finance Unit.

Job Description

  • Develop and execute strategic initiatives and programs to enhance existing Medicare claims processing functions in support of corporate initiatives and requirements
  • Recommend changes for system design, methods, procedures, policies, and workflows affecting Medicare claims processing
  • Participation in development, testing and implementation of new and or revised system enhancements to ensure effective and efficient Medicare claims processing 
  • Provide guidance in the investigation and final disposition of complex claims matters from Executive/Senior Management
  • Act as a consultant for the executive management from other departments for, but not limited to reimbursement methodologies, processing protocols and provider contract negotiations
  • Monitor claims inventory, cycle time processing and work quality to assure conformity with corporate objectives and departmental goals and BPO contract
  • Procedures management reports relative to inventory, productivity, accuracy, and cycle time
  • Maintain regular interaction with all MetroPlus departments relative to Medicare policies, procedures, and regulatory requirements
  • Review new contract business requirements relative to benefits and Medicare claims processing
  • Conduct special projects/studies; participates in various work groups upon request
  • Ensure adherence to all CMS Claims Processing Legislative and Regulatory requirements
  • External contracts may include written and/or verbal contracts with hospitals and physicians 
  • Other duties as assigned by the Associate Executive Director of Claims Operations 

Minimum Qualifications

  • Bachelor’s degree or related experience in an insurance or related field
  • Minimum three (3) Years of Medicare claims insurance or health care compliance required. Must have working knowledge of CMS claims processing requirements related to Medicare Advantage Plans
  • Clinical or billing/coding experience is strongly preferred. Excellent communication, critical thinking and decision-making skills required 
  • Knowledge process improvement/maximum operational efficiency preferred
  • Demonstrate knowledge of CMS, state and federal regulations and laws impacting Medicare Managed Care, Medicare and Medicare Part D Claims preferred

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication