Claims Research Analyst (Full time, Morrisville, NC Based)

The Claims Research Analyst reviews and monitors adjudicated claims for file submission and upstream processing and communicates with provider agencies on claims submission, denial management, and system updates. This position serves to provide excellent customer service to provider agencies. This position facilitates training of providers and provides intermediate technical assistance. This position reviews auto-adjudicated claims and manually processes claims that pend for manual pricing or high impact criteria. This position analyzes available billing requirements, policies, procedures, and desk references to ensure proper protocol is practiced to accurately process claims. The CRA demonstrates and utilizes advanced analytical skills to process complex claims, analyze data, identify system issues, and utilize/build reports to enhance overall unit performance. This position aids in the leadership of the unit through facilitation of meetings, trainings, and process improvement efforts. The position requires the application of technical skills, communication across all departments including Utilization Management, Provider Networks, Finance (Purchasing, Accounts Payable, Accounting), Care Management). The position requires communication with external stakeholders including DHHS, DSS, DHB, provider agencies, third-party vendors, and other Managed Care Organizations. The position requires a high degree of professionalism and productivity.

Responsibilities & Duties

Process Claims

• Review, key, process, status, track, and file Special Invoicing claims submissions which requires skill in managing and reconciling data between two information systems (finance/claims)
• Receive, review, analyze claims submitted via paper process to determine ability to process. If processable, key the claims accurately into the claims system
• Review and analyze received claims to determine accuracy of adjudication
• Identify adjudication errors, provider billing errors, and needs for technical assistance
• Monitor adjudication results using provided reports
• Apply basic claims knowledge in the review of patient and provider accounts to determine if account updates are needed
• Apply knowledge of eligibility, enrollment, prior approval, contracts, and credentialing to identify account needs
• Using existing reports, assure claims are processed within prompt payment guidelines
• Using Compliance Unit’s reversion packets, process refunds or adjustments
• Review claims for appropriate service event authorizations, consumer eligibility, and routine billing requirements
• Ensure appropriate coordination of benefits has occurred utilizing billing and payment policies and procedures
• Manually process claims unable to be adjudicated properly within MCS; including linking claims that error to the Exceptions Report
• Monitor and resolve technical issues within the Claims system
• Utilizing existing reports, monitor, track, and resolve Patient Monthly Liability corrections on provider claims and within NCTracks
• Review policy requirements associated with new or additional services to be processed and apply the knowledge to the processing of associated claims

Reporting

• Utilize reports to identify and resolve claims errors or updates
• Create reports to monitor status of billing, including: paid and denied provider claims; unmanaged and managed service utilization, and consumer or payer-specific reports on claims reimbursement or adjudication

Communication 

• Communicate and conduct liaison work across multiple departments to resolve claims denials/issues
• Communicate with high level external stakeholders like DHB, DHHS, and DSS 
• Communicate with internal stakeholders (all departments)
• Communicate with provider agencies
• Demonstrate professional and timely communication 

Provider Support

• Provide training, education, and technical assistance to provider agencies related to basic claims submissions guidelines, denial management, MCS system use and updates, state/federal claims submissions regulations and updates
• Develop training materials to facilitate trainings

Assist with Claims Process Improvement

• Identify resolution of system errors, review impact reports, communicate with providers and determine steps for reconciliation
• Provide information and feedback to the system team to support development of system enhancements in a structured manner aimed to eliminate system settings and or processes that contribute to poor results
• Maintain processes that are consistent with and compliant to CMS, state, federal and URAC standards, regulations and guidelines
• Read, review, analyze, and apply information from published clinical