Hospital Claims Coordinator

Description

Responsibilities

• Ensure timely/accurate processing of hospital claims at the Coordinator dollar-level, correspondence, and Call Tracking tickets according to 1199 Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters, coordination of benefits (COB), regulatory and pre-authorization requirements, Medicare National Correct Coding Initiative (NCCI) rules, provider, repricing network contract terms and timeframes, Fund and departmental policies
• Resolve complex claim issues involving: 1^st, 2^nd, and 3^rd level (IPRO) appeals; foreign claims; spreadsheet projects; reconsiderations; inquiries; adjustments; pending  reports/DMS queues; medical records; e-mail communications; MedReview and  Diagnostic Related Group determinations. Coordinate with QNXT Production Support, Provider Relations, Eligibility, Care Management, Liens, Member Services, and Outreach where necessary
• Provide quality assurance and technical support of hospital claims processing; analyze discrepancies between executed contracts and QNXT system pricing, to ensure appropriate rates, groupers, and attributes are loaded for adjudication
• Conduct system testing of related to QNXT upgrades, system enhancements, and external vendor processes
• Act as liaison between Fund and external vendors (i.e. ExpressScripts/CareContinuum, Evicore) to resolve authorization and unit reduction issues    
• Process all aspects of Medicare Secondary Payer (MSP) claims: to include adjudication of claims, and creating correspondence in response to Medicare third-party agencies
• Review hospital claims reports for duplicates, auto-adjust authorization download issues that require intervention as a result of system limitations and manual workarounds
• Analyze overpayment and unsolicited refund data from the Claims Recovery unit to determine trends, identify system issues and payer errors; make recommendations for mitigation/process improvement    
• Assist management in optimizing workflows, auditing of staff, providing checks and balances for strategic reports and in making recommendations to assist in coaching and mentoring opportunities 

• Perform additional duties and projects as assigned by management

Qualifications

• Bachelor’s degree in Business, Healthcare or Public Health Administration preferred, or equivalent years of experience
• Minimum three (3) years experience working in hospital claims processing, claims auditing, or quality assurance
• Strong organizational, analytical, problem-solving, critical thinking and time management skills
• Demonstrated ability to efficiently manage multiple projects, work well under pressure, establish priorities, meet deadlines, and follow through on assignments
• Excellent knowledge of CPT, ICD-10, HCPCS codes; UB-04 fields; claims reimbursement methodologies; ability to read/navigate QNXT and Vitech systems; intermediate knowledge of Microsoft Word and Excel
• Strong knowledge of Coordination of Benefits (COB) and Medicare Secondary Payor regulations  
• Effective oral/written communication; demonstrated ability lead/motivate others; work in a collaborative team environment

We offer extraordinary benefits including outstanding health, dental, pension and family benefits for most positions which are paid entirely by the Funds without co-payments, deductibles, or out-of-pocket expenses for covered services. We also offer tuition reimbursement, generous holiday, vacation, and sick leave, as well as a 401K plan.