Medical Claims Negotiator I

POSITION SUMMARY

Negotiate out-of-network claim payments with providers on behalf of group health plans. Such negotiations will be based on 1) various types of cost data, including “reasonable and customary” benefit levels and Medicare pricing, and 2) billing irregularities.

ESSENTIAL FUNCTIONS

• Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
• Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
• Contact providers to negotiate discounts.
• Reprice claims to the applicable Medicare rate.
• Log negotiated claims into the Access database and create weekly summary reports.
• Review and understand the terms and conditions of each client’s customized plans.
• Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, and any regulations promulgated thereto.
• Request, review and analyze any physician notes, hospital records or police reports.
• Consult with other entities who can offer additional evaluation of a claim.
• Process claims in the QicLink System.
• Review, analyze and add applicable notes to the QicLink System.
• Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Analyze claims for billing inconsistencies.
• Review and analyze specific procedure and diagnosis codes for medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Review Suspended Claim Reports and follow up on open issues.
• Assist and support other team members as needed and when requested.
• Attend continuing education classes as required, including but not limited to HIPAA training.
• Performs other related duties as assigned

EDUCATION

• Bachelor’s degree or equivalent work experience required.

EXPERIENCE AND SKILLS

• A minimum of 5 years of medical claims analysis experience required.
• Must have strong analytical skills.
• Must have knowledge of computer systems and CPT and ICD-9 coding terminology.  

POSITION COMPETENCIES

• Job Knowledge

• Time Management
• Accountability
• Communication
• Initiative
• Customer Focus

PHYSICAL DEMANDS

This is a standard desk role – long periods of sitting and working on a computer are required.

WORK ENVIRONMENT

Remote

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensa