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Claims Management - Claims Research Specialist

Tabula Rasa Healthcare Saint Louis ,MO
  • Posted: over a month ago
  • Full-Time
  • Benefits: 401k, dental, life_insurance, medical, vision
Job Description

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.

Essential functions:

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


Additional Functions:

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

Occasional bending/stooping

Work Environment:

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

Company Description
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.

Tabula Rasa Healthcare

Why Work Here?

Growing company with casual environment, generous benefits and growth opportunities!

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.

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