Claims Recovery Analyst - (Menasha) in Appleton, Wisconsin For Sale

Network Health's success is rooted in its mission to enhance the life, health and wellness of the people we serve. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Claims Recovery Analyst . This individual is responsible for understanding and differentiating between all group and individual products and business lines. Follows established departmental policies and procedures, operating memos and corporate policies to review, analyze, adjudicate claims, and resolve claim issues. Investigates potential refunds and processes requests from Providers and Members due to overpayment or inaccurate payments. Processes incoming checks and corrects the Network Health Claim Processsing system. Reviews pay cycles prior to release for negative balances and posts payments. Assists management with staff development, identifying and troubleshooting claim issues, various reports/projects, and claim adjustments. A qualified candidate will have a desire to work with a "values driven" organization while having the ability to communicate effectively, remain organized, and have ability to apply analytical thinking to identify and solve problems. Essential Job Duties: Commitment and behavior aligned with the philosophy, mission, values and vision of Network Health. Processes professional and facility claims for payment in accordance with members Certificate of Coverage/Summary Plan Description, established company policies and procedures, Wrap contracts, and plan benefit interpretation while maintaining established department quality/accuracy. Investigate & research refund receipt, reprocess applicatble claims based on refunds received. Run monthly negative vendor report and requests refunds based on outstanding balances and refers outstanding balances for collections. Processes corrected claims upon receipt from providers. Runs reports as requested. Investigate & researches returned Network Health checks, reprocess applicable claims. Review refunds and corrected claims received due to subrogation or third party payments. Forward applicable information to the subrogation company of claims reprocessed due to third party liability. Assists Management with projects, work production, claims adjustment reports, and prioritization of work activities to ensure team and department goals are obtained. Keeps current on all business programs, including, products offered, group contracts and certificates, provider discounts, percentages and per diems, authorizations and other utilization management policies, etc. Reviews and processes high dollar claims related to Recovery up to $50,000. Reviews claims to ensure compliance with proper billing standards and completeness of information. Acts as a liaison between Payment Integrity and Recovery and other operational departments for claim recovery issue resolution. Assists with the growth and performance of team. Assists training of new associates. Demonstrates leadership skills. Assists with leading team meetings and effectively communicates information to the department. Monitors and shares information and procedural guidelines among departments. Processes corrected claims and claim follow up forms in an accurate and timely manner. Makes recommendations by performing root cause analysis regarding any system-related problems to enhance efficiencies and savings to the Plan. Handle special projects and testing as assigned by Management. Reviews and follows up on pended claims weekly to ensure claim resolution is within established timeframes. Actively participates in shared accountability and commitment for departmental and organization-wide results. Support departmental/team goals and objective. Performs other duties as assigned. Skills Required: Excellent communication, critical thinking and decision making skills. Knowledge of process improvement/maximum operational efficiency preferred. Excellent time management skills with ability to prioritize and manage multiple demands. Understanding of all Commercial and Medicare plans and systems. Ability to track and report necessary information for reporting of recovery initiatives. Minimum Education Required : High school diploma or equivalent Minimum Related Years of Experience ( per minimum education ) Required: 3-5 years claims processing experience. Knowledge of Current Procedural terminology (CPT) and International Classification of Diseases (ICD-9 and ICD-10), and DRG coding. Advanced medical terminology, and COB processing Company Description: Ministry Health Care is a network of hospitals, clinics, and other health related organizations operating across the central, northern, and northeastern regions of Wisconsin and eastern Minnesota. To meet the needs of the communities we serve, we offer a complete continuum of care through acute and tertiary care hospitals, physician clinics, long-term care and assisted living facilities, home health agencies, hospices, and numerous other programs and services.
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