Employment Type : Full-Time
Claims Management - Claims Research SpecialistSt. Louis, MO, USA Virtual Req #600 Tuesday, August 17, 2021 Other details Hourly No High School
Tabula Rasa HealthCare (TRHC) is a leader in providing patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize performance to improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. Medication risk management is TRHC’s lead offering, and its cloud-based software applications, including EireneRx® and MedWise™, provide solutions for a range of payers, providers and other healthcare organizations.
TRHC empowers our employees to provide excellent service, utilize advanced technology, and proficiently deliver results. Our 32Fundamentals are what we are and who we are. Our culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement. As a part of our team, you will help us bring innovative service models to healthcare, improving patient outcomes.
Job Description: Claims Research Specialist
Summary: Under the direction of the Claims Payment Integrity Manager, 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 Serves as a champion for the TRHC 32 Fundamentals 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:
Physical Demands & Requirements:
Work Environment:
Supervised By: Claims Payment Integrity ManagerThe Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.