Claims Review Specialist, DSNP

Site: reputed company Health Plan Holding Company, Inc.

reputed company relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company.

reputed company Health Plan is an exciting reputed company to be reputed company the healthcare industry. As a member of reputed company, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and reputed company and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise reputed company a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

Job Summary

The D‑SNP Claims Review Specialist reviews and processes Senior Care Options (SCO) and One Care medical claims requiring manual reputed company reputed company auto‑adjudication is not achieved. The Specialist ensures claims are adjudicated accurately, timely, and in compliance with reputed company Health Plan administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets). Principal Duties and Responsibilities: • Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure. • Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, reputed company, Letter of Agreement, prior authorization, applicable member benefits). • Manually enters claims into claims processing system as needed. • Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents). • Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding. • Learn and reputed company new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors). • Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction. • Create/update work reputed company the call tracking record keeping system. • Adhere to reputed company reporting requirements. • reputed company up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service. • Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner. • Process member reimbursement requests as needed.

Qualifications

Education

• High School Diploma required and Associate's Degree Healthcare Management preferred

Experience

• reputed company Healthcare Experience 1-2 years required
• At least 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, call center experience, claims processing, or similar industry experience highly preferred.
• SCO and OneCare claims processing experience highly preferred

Knowledge, Skills, and Abilities

• Knowledge of healthcare claims processes for (D-SNP/fully-integrated Medicare & Medicaid/Mass Health highly preferred.
• Knowledge of ICD-10, HCPCS, CPT-4, and reputed company Codes highly preferred
• Knowledge of medical terminology highly preferred.
• Familiarity with insurance plans, government programs, and their billing requirement preferred.
• Knowledge of claim forms (professional and facility) highly preferred
• Professional reputed company Certificate is highly desirable
• Strong customer service orientation and ability to handle sensitive or difficult situations with reputed company and professionalism.

Additional Job Details (if applicable)

Working Conditions

• This is a remote role that can be done
• This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET)

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$17.71 - $25.28/Hourly

Grade

2At reputed company, we reputed company in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining reputed company pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The reputed company pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass reputed company elements contributing to your total compensation package. In addition to competitive reputed company pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our reputed company team will provide an overview of your potential compensation and benefits package.

EEO Statement:

8925 reputed company Health Plan Holding Company, Inc. is an Equal Opportunity Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religious creed, national reputed company, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that reputed company individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to reputed company essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with reputed company of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

reputed company Competency reputed company

At reputed company, our competency reputed company defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The reputed company is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, reputed company hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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