Clinical Editing Dispute Review Analyst 1

Description:

Summary Description:
Responsible for triaging, researching and resolving clinical editing review request inquiries for all current and future Clinical Editing programs for all regions. Creatively researches and resolves processing issues through working with multiple sources, including external vendors, as needed.

Essential Resource Responsibilities / Accountabilities:
- Coordinates inquiries by obtaining information from appropriate Medical Directors at in-plan IPAs, at Health Plan, Medical Claims Review nurses, internal staff and external customers as needed. Ensures turnaround times are met (as applicable)
- Assigns tracks and resolves specific clinical editing review inquiries. Develops and maintains logs as assigned. Maintains and updates clinical editing dispute review database for reporting and metrics
- Composes and (e-)mails communication for approved/denied inquiries and/or information/problem-solving requests. Communicates review results to providers
- Monitors and reports timelines for inquiry review, adjudication and response
- Enters claim information in claims remarks screen, indicating claim is currently under inquiry or appeal
- Contacts provider offices as needed to obtain correct claim/ordering information
- Constructs information for claim adjustments and forwards to Claim Research Unit
- Develops and prepares metrics to monitor department inquiries and functions on a weekly basis. Reviews logs, metrics and research issues with supervising staff
- Troubleshoots and identifies trends and recommends process gliches/improvements
- Represents the Clinical Editing Team as needed at other project teams that directly or indirectly impact coding requirements, claims processing or provider reimbursement\Provides support for Correspondence, Claims and Provider Service units related to appeals
- Supports other member and provider appeals functions, as needed
- Supports other ClaimCheck appeal functions, as needed

Minimum Resource Qualifications:
- Bachelors degree in relevant field with a minimum of three years experience with claims operations or customer service. In the absence of a Bachelors degree, significant work experience (minimum of five years) with coding, claims system operations and clinical editing tools may be substituted
- Certified Professional Coder (CPC) desired. Enrollment in CPC class within one year of hire required
- Experience/proficiency with spreadsheet, database, word processing, and coding software products required
- Excellent problem solving ability and skill in communicating complex ideas
- Experience in health systems operations including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products (e.g. Medicare, Medicaid, DRG, APC, RBRVS, CPT, HCPC, ICD9, etc)
- Understanding of the functionality and use of coding software products (e.g. ClaimCheck, Correct Coding Initiative (CCI))
- Understanding and extensive experience with claims processing systems (preferably CAPS/UWIN, LRSP, TOPPS, and FACETS), claims flow and adjudication process, system edits and display screens
- Strong communications skills including ability to present information
- Ability to follow-through with tasks independently
- Requires attention to detail and a customer-oriented attitudePhysical Requirements:In support of the Americans with Disabilities Act, this resource requirements document lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer:
Excellus Client Client is an Equal Opportunity Employer. As such, requires all suppliers of temporary staffing resources to affirm the rights of every person to participate in all aspects of employment without regard to race, color, sex/gender, age, disability, religion, creed, citizenship status, national origin, veteran status, military status, marital status, familial status, domestic violence victim status, sexual orientation, gender identity, predisposing genetic characteristic, genetic information, or any other status protected under the law.
EEO:

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”