About PEAK TPA
Peak TPA is a third party administrator (TPA) that provides back-office functions for capitated health plans. Back-office functions include but are not limited to claims adjudication, member enrollment and reporting, and financial reporting. Peak TPA's partner company, Mediture/Cognify, has a long history in providing software solutions for managing care coordination for capitated health plans. Both companies (subsidiaries of Tabula Rasa Healthcare Company) work closely together to provide integrated and intuitive products to our health plans. Peak TPA's goal is to seamlessly handle our client’s back-office functions to allow the plan to financially thrive and grow so they can focus on member care coordination.
Job Description: Claims Research Specialist
Summary:Under the direction of the Director of Implementation and Configuration, the Claims Research Specialist is primarily responsible for coordinating the resolution of claims issues by actively researching and analyzing systems and processes that cross multiple operational area and performing analysis of identified claims issues and interpreting results to identify barriers to appropriate claims payment. The Claims Research Specialist also recommends ongoing improvements to processes report outcomes ensuring that claims are selected for payment according to client regulations and client processing rules.The position leads the problem-solving and coordination efforts among various business units.
Audits check run and send claims to the claims department for corrections
Identifies system changes and work with Provider Network and Configuration to implement changes
Collaborates with the claims department to price pended claims correctly and automate pends as necessary
Documents, tracks and resolves all plan providers claims projects
Collaborates with various business units to resolve claims issues to ensure prompt and accurate claims adjudication
Identifies authorization issues and trends and research for potential configuration related work process changes
Analyzes trends in claims processing issues and assist in identifying and quantifying issues and reviewing work processes
Identifies potential and documented eligibility issues and notify applicable departments to resolve
Researches the claims on various reports to determine if appropriate to move forward with recovery due to non-covered items being allowed, etc.
Runs claims reports regularly through provider information systems
Researches verbal and written providers claims inquiries as needed
Coordinates with Encounters team to ensure claims processes align with encounter requirements
Assists with special projects, as requested
Communicates clearly and concisely, with sensitivity to the needs of others
Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
Maintains courteous, helpful and professional behavior on the job
Establishes and maintains effective working relationships with co-workers
Ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards
Follows all Policies and Procedures and HIPAA regulations
Maintains knowledge and understanding of current Medicare regulations related to PACE Health Plan Management.
Maintains a safe working environment
Maintains knowledge and understanding of current Medicare claims processing guidelines
Attends continuing education seminars as requested
Supervisory Responsibility: None
Travel: No travel is anticipated for this position.
Knowledge, Skills and Abilities:
High School Diploma or equivalent required
Two years of claims processing, coding, or healthcare analytics experience with TPA or Health Plan required
Experience working with Managed Care programs strongly preferred (Medicare, Medicaid, LTSS, DSNP, MMP, etc)
Experience with provider contracts and contract interpretation strongly preferred Intermediate level of current, demonstratable experience with Microsoft Excel requiredSkilled in establishing and maintaining effective working relationships with clients, and staff at all levels
Skilled in data analysis and problem solving using defined methodologies
Ability to work independently with minimal supervision
Ability to independently follow through on projects
Ability to communicate professionally, clearly and effectively, verbally and in writing
Ability to prioritize effectively
Ability to consistently multitask
Ability to understand issues, demonstrates resourcefulness, and resolve issues in a timely manner
Ability to demonstrate good judgment and have excellent critical thinking skills
Physical Demands & Requirements:
Communicate by way of the telephone with participants, customers, vendors and staff
Operate a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
Remain stationary for extended periods of time
Occasionally exert up to 20 pounds of force to lift, carry, push, pull or move objects
Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
Occasional reaching to retrieve shelved items
This job operates in a professional or home office environment with a conversational noise level.
No substantial exposure to adverse environmental conditions is expected.
Moderate pressure to meet scheduled appointments and deadlines
Potential for occasional verbal aggression by clients and vendors
Supervised By:Director of Implementation and Configuration
Tabula Rasa Healthcare
Why Work Here?TRHC provides patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize medication regimens. We improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. We deliver our solutions through a comprehensive suite of technology-enabled products and services for medication risk management and risk adjustment.
Growing company with casual environment, generous benefits and growth opportunities!