Especialista de Reconciliacion y Monitoreo de Montaje

Regular

Exempt

GENERAL DESCRIPTION:

Responsible for evaluating the setup process of all Providers, ensuring that processes and procedures are correctly applied according to MCS payment policies and rules for all lines of business.

ESSENTIAL FUNCTIONS:

• Serves as an expert to management and other departments in matters related to payment application, method of setting up providers and service codes, reconciliation process and monitoring of claims, and pending cases that need the intervention of other departments.
• Analyzes and validates the setup of what has been contracted with Providers, performing claims sampling, all types of adjustments, and recoveries.
• Evaluates all service codes referred to their attention, identifying situations that may affect provider payments. Contacts the corresponding area for the requested task configuration, verifies after its configuration that it is correct, and certifies it to close the ticket.
• Identifies situations that may affect the provider configuration, analyzes what has been requested, and, if necessary, provides recommendations to the requesting staff.
• Verifies and validates Medicare policies and performs appropriate research with the Centers for Medicare and Medicaid and other policies established by other regulatory agencies.
• Coordinates all matters related to the Power MHS adjudication process and follows up as necessary on service requests along with the Systems Department.
• Validate the Grievance and Appeals investigations related to the Provider settlement setup process.
• Develops analysis of findings from audits performed on providers to make reports and presentations as required.
• Investigates duplicate payments to ensure that the system is making the correct determinations for these types of claims following the contracting agreements with Providers.
• Identifies overpayments made to providers and refers them to the Recoveries Unit for evaluation.
• Coordinates the resolution of claims referred for evaluation and payment determinations along with other departments.
• Samples claims to review the claims adjudication process related to the most common EOP-Hold Codes to determine if the system is adjudicating claims correctly and evaluates the need for code revisions.
• Requests new EOP-Hold Codes or deactivation of EOP-Hold Codes, and/or change of EOP-Hold Code status (deny, warning, pend, etc.).
• Investigates and refers any problems with electronic claims transmissions to the Department Delegated Entities Unit.
• Performs analysis of Fee Schedule and benefit screens to establish process guidelines for providers and benefits setups.
• Analyzes provider contracts settings to determine payment fees applicable to services.
• Prepares periodic and "ad hoc" reports as required.
• Complies fully and consistently with Company standards, policies, and procedures, along with local and federal laws applicable to our industry, business, and employment practices.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's degree in areas related to Business Administration. Minimum of three (3) years of experience in claims, provider service, or configurations.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: N/A

Other: Knowledge of medical claims or medical billing-related management. Knowledge of hold code structure and configuration of benefits and providers. Knowledge in Coordination of Benefits and Major Medical. Knowledge of the contracting process. Knowledge of CPT, HCPS, and diagnosis codes.

Languages:
Spanish – Intermediate (writing, conversational, and comprehension)
English – Intermediate (writing, conversational, and comprehension)

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