The Medicaid Review Analyst will be responsible for initiating, supporting, monitoring and evaluating medical review activities, including compliance with program deliverables, internal and external performance requirements, and continual improvement. This position is responsible for providing support to the Data Processing Review Management staff and Operations area.
· Extensive travel (air/car) – 60-75% per year - with your team to scheduled states for Data Processing reviews. Travel will generally be Sunday through Thursday and/or Friday based on workload.
· Complete Data Processing reviews in accordance with internal and CMS metrics/timeliness requirements.
· Communicate and collaborate process improvements identified to the Data Processing management team to ensure we continually meet and exceed expectations.
· Review and analyze multiple claim processing, eligibility enrollment, and provider enrollment systems. Make an informed decision to determine if the information in all systems resulted in an accurate payment determination.
· Independently research complex situations, arrive at an accurate conclusion. Work with Senior reviewers or Leads when assistance is needed in completing reviews.
· Consult with Senior Reviewers and Leads about the implication of how state and federal policies and regulations are applied in differing claims scenarios.
· Collaborate with Senior Reviewers and Leads about how state and federal policies and regulations are applied to specific claim scenarios in front of stakeholder staff. Collaborate directly with stakeholder staff and the customer about complex review scenarios and how state and federal regulations are applied.
· Prepare responses to ad hoc questions from Data Processing Management related to complete or in progress reviews.
· Coordination with IT staff and stakeholder IT staff to complete reviewer access forms for the state MMIS systems.
· Monitor Claim Payment Systems and notify management of potential problems/errors and of potential areas for improvement.
· Enter final decisions into system and prepare reports as needed.
· Complete assignments in a manner that meets or exceeds the quality assurance goal for accuracy.
· Maintain chain of custody on all documents and follows all confidentiality and security guidelines.
· Performs other related duties as assigned
Required Skills and Abilities:
· Extensive knowledge of medical terminology and coding principles.
· Ability to read insurance claims, both paper and electronic, and a basic knowledge of insurance claims systems
· Ability to read and understand complex Medicaid policies.
· Knowledge of and the ability to correctly identify insurance coverage guidelines
· Familiarity with CPT codes, ICD-10-CM codes, and HCPCS codes
· Strong critical thinking and decision-making capability.
· Ability to quickly adapt and thrive in a changing work environment.
· Ability to read insurance claims, both paper and electronic, and a basic knowledge of the insurance claims systems
Required Education and Experience:
· Bachelor’s degree or equivalent work experience
· Minimum two (2) years' experience with Medicaid/CHIP data.
· Minimum two (2) years' experience with Medicaid/CHIP policy.
· Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
· Must live within reasonable commuting distance of a major airport.
· Must have and maintain a valid driver's license for the associate’s state of residence.
· Fingerprint background check may be required.
Office Equipment Required: (This is a work from home position with extensive travel.)
· Locking cabinet and/or desk for storing documents and electronic media
· Cross-cut shredder
· Broadband internet connection
· Phone line (land line or cellular)
· May required prolonged periods of sitting at a desk and working on a computer