General Summary:

The claims Process Coordinator is responsible and accountable for the following essential functions including the accurate and timely claims processing of all claim types. Claims must be processed with a high level of quality and in accordance with claims payment policy and the terms of our customer/provider contractual agreements. 

Principal Duties and Responsibilities:

Investigate and resolve Pega cases within HAP divisional processing standards for all products. Adjust claims to determine authorization or rejection and determine appropriate amounts for payment, which includes resolving claim edits. Manage the Appeals and Grievance claims workbasket in Care Radius. This involves a partnership with the Appeals and Grievance team to research and effectuate claims. Enter and process appeals with Data iSight. This involves managing a workbasket in Pega as well as working through the Data iSight portal for provider and member appeals. Investigate, process, and resolve direct member reimbursement requests. Work as part of a team to resolve claim related inquiries from members, providers, and other departments within HAP. Maintain knowledge of claim workflow holds to be able to review and resolve claims inquiries in relation to the correct processing of claims. Perform research using BAM, EOC, Claims Resolution Guide, Procedure and Reference list and other resources necessary to resolve claim issues completely and accurately. Responsible for technical service requests, creating and responding to BCT help desk trouble tickets as needed. Outreach to providers via email or phone as needed. Attend and participate in meetings to collaborate with other departments and outside resources. Provide backup support to other team/group members in the performance of job duties as assigned. Perform other related duties as assigned.

Education Required:

 Associate’s degree in business, Healthcare, or related field. Related and relevant experience and a demonstrated ability to perform the duties of the position may be considered in lieu of academic requirements. Relevant work experience is defined as four (4) years prior experience in claims adjudication, claim inquiry resolution, and/or claim adjustment experience. 

Experience Required:

Four (4) years of related experience with multiple claims screens with demonstrated ability to investigate and process claim inquiries. Two (2) years of experience processing claim adjustments. One (1) year experience with the Data iSight appeals and the Data iSight portal.

Preferred:

Three (3) years of experience with HAP programs: Care Radius, Facets, Pega. Experience with the Data iSight portal.

Skills and Abilities:

Demonstrated analytical skills, maintain confidentiality with sensitive materials and communicate results to internal and external customers. Problem solving, analytical and decision-making skills. Self-motivated and directed with the ability to complete tasks with minimum supervision. Knowledge of Medicare processes and regulations. Knowledge of CPT, ICD-9, HCPC, and DRG coding. Knowledge of subscriber contract benefits, riders, plan requirements, and member obligations. Knowledge of HAP provider billing and coding requirements. Knowledge of provider pricing, claim payment, and adjustment processes. Excellent oral and written communication skills. Must have a high level of organizational planning and time management skills, complete follow-up and meet deadlines. Knowledge of insurance industry operations, health care benefits, structures, policies and procedures and medical coding. Familiarity with administrative and health care reimbursement data sources including standard code schemes (ICD 10, CPT, etc.). Demonstrated proficiency with Word and Excel. Additional Information Organization: HAP (Health Alliance Plan) Department: CLAIM PROCESSING Shift: Day Job Union Code: HAP Flint Non Exempt