Analyst, Claims

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Time Type:

Full time

Department:

PACE Health Plan Management

All Locations:

300 Ocean Avenue – Revere

Position Summary:

Position Summary:
The Claims Analyst, under the direction of the Manager of PACE Claims, is responsible for the overall claims adjudication and insurance validation process. This includes:

Claims Department:
•Maintaining up-to-date knowledge of fee schedules for both Medicare and MassHealth.
•Ensuring the fee schedules are updated and are priced correctly in the Tapestry module.
•Auditing adjudicated claims to ensure payments are made in accordance with their contracts.
•Analyzing claims data to ensure accruals are reported to Finance in a timely and accurate manner.
•Ensuring accuracy of claims-related cost reports.
•Analyzing claims data for trends (e.g., referral matching).
•Reporting any findings to PACE leadership.
•Coordinating with IT to enhance and refine the claims adjudication process.
•Coordinating with the Manager of PACE Claims to proactively review referrals and claims-related data in an effort to provide utilization reports to other departments.

Insurance Department:
•Must maintain up-to-date knowledge of Coordination of Benefits.
•In conjunction with the Supervisor of Business Services, responsible for assisting with and developing workflows to maintain overall compliance of the Insurance Department.

Schedule: Monday - Friday 8:00am - 5:00pm

Insurance Department

• Serves as the department Medicare expert. This includes auditing enrollment files to ensure compliance with the Part D requirements: EOBs, COB follow-up is completed timely and accurately, as well as documentation in EPIC regarding MSP surveys and TrOOP.
• Ensures primary insurance coverage is documented in EPIC and that insurance billing is appropriate.
• Responsible for the timely completion and documentation of CMS Part D reports: COB, MSP.
• Serves as back-up for Business Services Supervisor.

Expense Management/Claims

• Monitors monthly expense reports to ensure that all expenses are correctly categorized and reported.
• Oversees the referral authorization process as it relates to timely and accurate claims payment and improvements to utilization management.
• Responsible for maintaining up-to-date knowledge of fee schedules and works with IT to ensure timely upload into Tapestry.
• Coordinates with the Manager of PACE Claims in an effort to improve the processes to manage claims payment and expenses based on trends analysis.
• Acts as the department claims expert regarding adjudication.
• Audits claims work queues to ensure timely and appropriate payment to vendors; suggests process improvements (e.g., referral matching table edits).
• Coordinates with Finance to ensure appropriate accruals on a monthly basis. Reviews IBNR data with Finance in an effort to ensure all claims are received.
• Works closely with the Contracts Department to review reimbursement.

Information Technology

• Serves as a liaison with IT, specifically regarding Tapestry (fee schedule development, claims processing, referrals) and reports and workflows related to ESP (Elder Service Plan) Business Office processes.

Other Duties

• Regularly reports to work on time and follows attendance and call-in procedures.
• Works cooperatively and respectfully with others at all levels of the organization.
• Takes the initiative to perform a wide variety of activities and be flexible in terms of work assignments based on operational needs, contributing to the smooth functioning of the department.
• Displays outstanding customer service skills when interacting with all NH customers according to the PACE model.
• Creates and/or revises policies and procedures, workflows, and guidelines, as appropriate, in any respective areas under the Business Office or as requested by Manager.
• Other duties as required.

PACE AND GENERAL REQUIREMENTS: KNOWLEDGE, SKILLS AND ATTITUDES (This section not applicable to initial assessment; all ESP employees and contractors attain these competencies through participation in PACE and TJC orientation programs.)

• Demonstrates commitment to the PACE mission by actively promoting the autonomy and dignity of PACE program participants.
• Demonstrates commitment to a holistic approach to care by actively engaging in interdisciplinary team planning and communication processes.
• Demonstrates commitment to participant-centered care by actively engaging participants and/or Health Care Proxies in discussion about self-management goals.
• Understands ESP’s organizational structure. Actively participates in NH programs and committees.
• Demonstrates the ability to communicate effectively and respectfully through verbal and written skills. Documents in accordance with protocol.
• Demonstrates knowledge of Participant Rights by:
• actively protecting rights to privacy;
• always treating participants with respect;
• encouraging and assisting participants in filing of complaints and grievances;
• helping to maintain a clean and safe environment;
• helping to ensure that restraint and involuntary seclusion are never used as a means of coercion, discipline, punishment, retaliation, or for the convenience of staff; and that those restraints, when required by extraordinary circumstance, are always applied and monitored in accordance with policy/procedure.
• Promotes a sense of “teamwork” through demonstration of self-direction and self-motivation. Solves problems independently or knows when to seek consultation. Provides leadership to other support staff on the practice team. Works cooperatively and respectfully with others at all levels of the organization.
• All ESP employees participate in the orientation, training, and mentoring of new employees and in providing input for continuous improvement.
• Displays outstanding customer service skills when interacting with ESP participants, family members, outside providers, potential ESP members, referral sources, or others.
• Interacts with participants in a professional and respectful manner that reflects the needs and concerns of the individual. Maintains a positive attitude. Uses communication devices appropriately.
• Demonstrates commitment to performance improvement by reporting incidents and other data used in ESP Performance Improvement activities, and by actively participating in one or more performance improvement committees or making a minimum of two suggestions for program or other improvements over the course of the year.
• Responsible for continued professional growth and development.

Pay Range: Starting at $26/hr up to $39/hr based on experience

EEO & Accommodation Statement:

NeighborHealth is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail toHRrecruit@NeighborHealth.com or call 617-568-4480 to let us know the nature of your request

Federal Trade Commission Statement:
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website. We do not ask or require downloads of any applications, or “apps.” Job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.

E-Verify Program Participation Statement:

NeighborHealth participates in the Electronic Employment Verification Program, E-Verify. As an E-Verify employer, all prospective employees must complete a background check before beginning employment.