Responsibilities

Responsible for the adjudication of complex facility claims including hospital, durable medical equipment, home health services, skilled nursing facilities as well as associated professional claims. Essential job functions include: Apply knowledge of Centers for Medicare & Medicaid Services (CMS) rules specific to DRG pricing methods, APC, Outpatient Prospective payment system mechanics (OPPS) and Contractual Payment Rates.  Position will work closely with Supervisor and Claim Services to complete request for claims adjustments via CRM Module. Review and interpret provider issues and member reimbursement requests. Utilize DRG and other pricing tools and apply applicable reimbursement outcomes claims. Conduct pre/post analysis of high dollar claims and present summary to management.

 

Job Title: Medicare Claims Analyst

Location: Remote

Department: Claims

Job Type: Full Time 

Salary Range: $ 45,657- $56,413 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)

 

Qualifications

Education

Required: Associate degree or 2 years Claims Payment Analyst experience in lieu of education

Preferred: Experience with Microsoft products (word and excel.)

Experience

Required: 3 years of Facility Claims Adjudication experience in a HMO,PPO, or TPA environment.

Preferred: 5 years’ experience as Claims Payment Analyst and demonstrated ability to process complex 

 

professional and facility claims.

License(s)

Required: N/A

Preferred: N/A

Special Skills

Required: Demonstrated understanding of DRG pricing methods, Outpatient Prospective Payment System 

 

Mechanics, Outliers and Case Rate Payment Mechanics. 

 

Knowledge of CMS rules and regulations. 

 

Skillful in medical terminology, CPT and ICD9 Coding and billing. 

 

Demonstrate strong working knowledge of Payor Contracts, Utilization Review procedures (specific to 

 

authorizations). 

 

Able to interpret and apply contracts, fee schedules and reimbursement methods. 

 

Ability to understand and/or interpret regulatory guidelines (i.e. TDI, CMS, HIPAA, etc.)   

 

Strong knowledge of Claims Services and Claim Review Processes.

Preferred: N/A

Other 

Required: Self-directed and able to absorb new material quickly

Preferred: N/A

 

Working Environment: Office

 

About Us

Start your career journey and become a part of a community of renowned Healthcare professionals.  Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties.  Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner.  Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares. 

 

Why Kelsey-Seybold Clinic?

Medical, Vision, and Dental Tuition Reimbursement Company Matching 401K Employee Reward and Recognition Program Paid time off for vacation, sick, and holidays Employee Assistance Program Continuing Medical Education allowance