Position: Claims Research Analys

Category: Non -Exempt

Location: To Be Determined (Can be at any of the 4 sites)

Salary Range: $32,144 - $40,143

Closing Date: Until Filled

Position Number: 17-04-709

Position Description:

Proactively communicate with provider agencies on claim submissions, denial management, and system functions through research and analyzing routine and complex claims data to determine that payments and settlements have been made in accordance with Eastpointe practices and procedures. Track trends and patterns sighted during research, Educate the provider community to foster successful submission of claims. This position is a primary communication point for providers experiencing an array of claims difficulties. This position serves to provide excellent customer service to provider agencies.

Responsibilities and Duties:

• Provision of excellent customer service while receiving calls from providers via the claim’s provider service line.
• Maintain provider satisfaction by being available during published service line hours to handle inquiries.
• Processing Claim Inquiry Forms received from providers, billing agencies and clearinghouses.
• Prompt response to all provider inquiries which may include

o Reviewing claims adjudication results to determine if claim events were accurately submitted and processed according to State and Federal claim edit requirements in addition to units of service are authorized for payment, fund source eligibility is correctly identified, consumers are eligible for services provided, and providers are eligible for reimbursement.

o Reviewing member/recipient and provider account updates in Eastpointe’s Core Administrative System and coordinating re-adjudication as appropriate; including for retroactive Medicaid coverage, retroactive authorizations, provider contract updates and clinician credentialing updates.

• Communicate and conduct liaison work across multiple departments to resolve claim denials/issues.
• Coordinating reprocessing of claims as appropriate when discrepancies or changes in beneficiary eligibility are identified.
• Providing training, education and technical assistance to provider agencies related to basic claim submission guidelines, denial management, system use and updates as well as state/federal claim submission regulations and updates.
• Serve as a resource for internal staff to resolve issues related to claims payment.
• Research using internal reports to analyze and respond to claims related questions initiated by Eastpointe staff across all levels of the organization, Providers, and the Division of Health and Human Services as well as to provide data to the same.
• Recognizing and reporting suspected system issues or concerns to immediate supervisor for follow-up.
• Reviewing member/recipient eligibility maintained in NCTRACKS.
• Document all communication with members and providers.
• Create reports as needed to aid in assisting providers.
• Review published claims related bulletins, manuals and announcements for new guidelines and updates to current guidelines.
• Attend and participate in training sessions to improve/enhance technical competence.
• Protect privacy of health information of members when using or disclosing PHI
• Additional functions as assigned to assist the department as work demands dictate.

Education/Experience: High School and 3 years’ experience in claims/reimbursement; or an equivalent combination of education and experience. Graduation from a four-year college university with a major in Business Administration may be substituted for the required experience; or a two-year degree in business administration or accounting from a community college may be substituted for two of the three years’ experience. Medicaid, NCTracks, Physical, pharmacy and Hospital claim knowledge a plus.

Excellent Benefit Package to Include:

• Employer paid Health, Dental, Life and Long Term Disability Insurance
• NC Local Government Retirement
• NC 401K with 4% employer match
• 13 paid holidays per year
• Monthly sick and vacation leave earnings