Claims Specialist at APS Health Care PR

, Puerto Rico, United States -

Full Time

Start Date

Immediate

Expiry Date

30 Mar, 26

Salary

0.0

Posted On

30 Dec, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Processing, Claims Auditing, Medicaid Regulations, Commercial Claims, CPT Coding, ICD-10 Coding, HCPCS Coding, Data Analysis, Root Cause Analysis, Process Improvement, Team Coordination, Fraud Reporting, Financial Recovery, Compliance, Training Development, Billing Analysis

Industry

Hospitals and Health Care

Description

Position Summary: The Claims Specialist (Auditor) position is responsible for assuring compliance with Medicaid, Commercial claims payment regulation. This position contributes to the identification and recovery of improper payments through management of claims audit timelines, billing, coding and payment analysis. Essential Functions: 1. Conduct research and analysis utilizing claims and direct member reimbursement policies and procedures; the Center for Medicare and Medicaid Services (CMS) Manuals and pricing established for the Medicaid and commercial lines. Responsible for maintaining knowledge base of Medicaid and Commercial rules and regulations. 2. Conduct claims and direct member reimbursements audits to evaluate compliance with Medicaid regulations and Commercial line. Responsible for identifying trends/concerns and conduct root cause analysis for identified concerns and document opportunities for improvement, make recommendations for process improvement, track, and trend performance for both claims analysts and claims process and develops trainings to address identified improvement opportunities. Evaluate the report where all the claims processed daily of the different products for the Medicaid and Commercial business lines sent by the supervisor are included. 3. Able to work efficiently in teams and fluidly switch between team and self-directed work priorities. Coordinate with Claims, Information Technology, and other internal and external business partners to analyze and resolve data submission issues at the organization, provider, and regulator levels. Evaluate letters of denied claims and identify those that correspond to the development carried out by the Claims Department to be informed of Compliance. 4. Reports possible instances of fraud and abuse, if found. Validation of the reimbursements worked by the Claims Department of the different products for the Medicaid and Commercial business lines. 5. The Financial Recovery Claims Auditor will generate assessment reports monthly, quarterly, or as required. The Financial Recovery Claims Auditor will ensure: The charges listed on the invoice are correct. The services were paid according to the amount agreed upon in the service contract. 1. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. 1. All other duties assigned by management. Education: * Associate degree or four (2) years of experience in a directly related field * Certification of compliance Medical Auditor, “CMA” Experience: * Minimum three (3) years of claims processing with minimum two (2) years of claims auditing experience. Knowledge: * Knowledgeable with insurance policy, Medicare regulations and general claim compliance * Experience in CPT and ICD-10 coding and different pricing tools. * Know several different coding systems, including Level 1 HCPCS and Level 2 HCPCS.

Responsibilities

The Claims Specialist is responsible for ensuring compliance with Medicaid and Commercial claims payment regulations through audits and analysis. This role involves identifying improper payments, conducting root cause analysis, and recommending process improvements.