JOB PURPOSE: The Claim Appeals and Audit Specialist will play a pivotal role in enhancing the efficiency and effectiveness of the claims department by timely and accurate processing of claims appeals and performing claims audit, ensuring payment integrity and compliance with all applicable State, CMS, and contractual guidelines. This position emphasizes the appeals review and auditing of claims to drive process improvements and achieve measurable outcomes. JOB RESPONSIBILITIES: + Perform end to end claims appeals review process. Track appeals and process the appeals into timely and accurate resolution. Address any issue with management. Work with other key stakeholders in making sure the recommended resolution is aligned with company policies and State/CMS guidelines. + Ensure accurate logging and processing of refund checks in the database, facilitating expedited credit of returned monies and proper application of transaction by our TPA. + Perform in-depth claims audit to confirm that all medical claims paid and denied accurately. Address any findings and observations with management and TPA for possible configuration update and fixes. + Perform ad-hoc claims analysis to ensure compliance and identify areas for improvement. + Maintain a high level of customer service for both internal and external customers, addressing inquiries and resolving issues promptly. + Investigate suspense conditions to determine if system or procedural changes could enhance claim workflow and efficiency. + Analyze patient and medical information to identify Coordination of Benefits (COB), Worker's Compensation, No-Fault, and Subrogation conditions. + Validate Diagnosis-Related Group (DRG) grouping and (re)pricing outcomes presented by the claims processing vendor to ensure accuracy. + Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments. + Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations. + Compile and analyze claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner. + Assist management with timely and accurate response to internal and external audit inquiries, including government agencies. + Other duties as assigned. Schedule: 8:30AM – 5:30PM Weekly Hours: 40 QUALIFICATIONS: Education: Bachelor's degree required. Experience: + 1-3 years of healthcare experience, managed care setting is strongly preferred. + Experience in claims appeals and/or claims audit within managed care setting (Medicaid and/or Medicare). + Claims adjudication and understanding of claims PPS is strongly preferred. + Knowledge of Medicaid and Medicare benefits, enrollment and billing, and provider contracting is strongly preferred. + Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS + Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software. + Effective oral, written, and interpersonal communication skills are required. + Able to multitask efficiently, effectively, and timely. + Strong organizational skills and work ethic. + Detail-oriented, professional and collaborative, a great team player. Physical Requirements Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to: + Standing – Duration of up to 6 hours a day. + Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods. + Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc. + Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job. + Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas. + Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.) + Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy. + Audio Hearing and Motor Skills (Language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. + Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job. Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company. We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Salary Range (Min-Max):$70,000.00 - $80,000.00