Insurance Claims Specialist
Operations
About the Role
The Insurance Claims Specialist will be responsible for assisting with oversight of Troy Medicare's claims adjudication process for its Medicare Advantage plans. This position is key in ensuring that all steps in claims processing are handled accurately and timely, demonstrates exceptional attention to detail when verifying information on submitted claims, reviewing the policy to determine which charges are eligible for reimbursement, auditing any vendor processed claims and investigating provider claim disputes and appeals. They ensure all business rules set by the Plan are followed by vendors and that payments are made according to CMS guidelines, Troy Medicare's provider contracts and plan benefit designs.
Troy Medicare started in Concord, North Carolina when our founders saw so many people increasingly unable to afford their prescriptions. Big health insurance companies had become more expensive and less transparent in their pricing and benefits. Our mission is to provide a comprehensive and easy to understand Medicare plan for every single member.
Responsibilities
- Perform operational monitoring and oversight activities of Troy's Claims operations, delegated to external partners/vendors, ensuring operations and performance meet all regulatory requirements and quality standards.
- Monitor, track and assist leadership in managing claims inventory; monitor daily reporting distributed by vendors (claim reports, document aged reports, etc.).
- Review and assist leadership with complex and specialized claim processing rules such as high-dollar or other claims flagged for plan.
- Resolve outstanding medical claims by approving or denying with adequate documentation for support; ensure that processes are handled in accordance with referred time frames and other contractual legal requirements.
- Partner with Configuration, Provider Data, Network and vendors to ensure claims are paid to providers and members accurately.
- Assist leadership in managing the day-to-day functions of the Plan's Claims operations ensuring appropriate processing, as well as investigation and dispositioning of questionable claims as well as member and provider claim disputes and appeals.
- Document medical claims adjustments by completing forms, reports, logs, and records.
- Produce and provide senior management with performance and adherence data, reports on trends and other similar deliverables.
- Review benefits configuration setup for accurate plan benefit change setup; provide recommendations on the design of claim payment system configuration.
- Review medical records for accurate diagnosis codes for Risk Adjustment submissions.
- Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support.
- Read, interpret, and formulate complex computer system rules and managed care reimbursement payment methodologies including but not limited to CMS payment rules and requirements.
- Partner with impacted business owners, entities and Compliance to remediate issues of noncompliance and track/report the status of corrective actions.
- Provide subject matter expertise and support to staff, business owners, Plan leadership and delegates.
- Support and participate in audits, coordinating with Operations Leadership, Compliance and Legal to ensure the Plan provides all the requested data; navigate systems as needed during audit and provide any follow up requested by auditors.
- Follow company policies, procedures, guidelines, as well as state and federal insurance regulations.
- Collaborate with staff, business owners and delegates on ways to improve adherence to business and regulatory requirements.
- Integrate regulatory updates and changes into departmental policies, procedures, job aids and/or other applicable resources as needed.
- Provide training and direction in developing procedures to comply with requirements.
- Perform other duties as assigned.
Requirements
- 4+ years of Medicare Advantage claim handling experience and demonstrated proficiency in analyzing and handling claims.
- 3-5 years of experience in Enrollment, Premium Billing, Claims, Member and Provider Service, and Appeals at a Medicare Advantage health insurance company will be considered in lieu of a degree.
- 3-5 years of experience in commercial facility and professional pricing methodologies (DRG, case rate, per diem, % of billed, fee schedule, etc.) and application of CMS billing guidelines required.
- Intermediate or advanced Excel skills for data analysis required.
- 3-5 years of complex managed care concepts/processes, and health insurance pricing and associated benefit design knowledge preferred.
- Strong understanding of insurance products, benefits, coverage limitations, laws and regulations as it applies to the health plan.
- Proficient in using MS Office products or other similar systems.
- Knowledge of systems and technology and proficiency with data analytics.
- Problem solving and critical thinking skills, with the ability to conduct research and identify steps required to resolve issues and follow through to completion.
- Excellent communication skills — both written and verbal — and active listening skills.
- Passionate about changing the healthcare experience for our members.
- Energized by helping people and seeing the positive impact of your efforts.
- Resourceful and enjoy solving complicated problems to get to the root cause.
- Self-starter, flexible, adaptable, highly organized, and proactive.
- Strong relationship building skills.
- Ability to learn quickly and adapt to change.
Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. Work involves exerting up to 20 pounds of force occasionally and/or a negligible amount of force constantly to move objects. The use of arm and/or leg controls requires exertion of force greater than that for Sedentary Work and the worker sits most of the time, the job is rated for light work.
The company is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.
Ready to apply?
If this role sounds like a fit, send your resume and a short note to our team. We review every application.
hr@troymedicare.com