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Maintains a working knowledge of all company managed care activities: Provider Contracting, Member Services, Utilization Management, Claims, Capitation, Enrollment Provider Relations, Finance, etc., to provide RPA, payment integrity and Facets Configuration solutions for the enterprise.
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Working knowledge of Managed Care information systems including QNXT and associated health care specific subject areas for Medical and Pharmacy Claims, Membership, Enrollment, Providers, etc.
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Minimum of 2-3 years of experience in a managed care claims processing environment required, including the processing of all medical claim types and the handling of complicated claims issues.
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We are looking for a motivated performer to join our Business Office team as a Collections Specialist, with an extensive knowledge of claims reimbursement and collection efforts for Managed Care, Medicare, Medicaid, Workers Comp, Commercial plans, etc.
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As part of this effort, Serco would execute the PERM review contract which includes collection of state eligibility policies and medical records; eligibility reviews, medical reviews, and data processing reviews, of selected state Medicaid and CHIP fee-for-services (FFS) and managed care claims; and supporting state and national reporting of payment error rate and development of corrective actions based on findings.
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Experience in provider network management, Medicaid/Medicare contracting, and/or claims processing preferred. Experience in marketing/sales, medical economics in a managed care or insurance environment.
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This will include overseeing and performing claims processing, contract maintenance, formulary and data validation, data management, report generation, trend insights, customer interaction and support, and documentation for Managed Care, Medicaid, Tricare and Part D rebates.
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Four (4) years of progressive experience implementing and supporting Electronic Data Interchange (EDI) processes in a managed-care environment, including the exchange of eligibility, authorization, claims, and other X12 transactional workflows required.
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Requirement: Claims Processing experience, Facility Claims knowledge and processing, experience in Health Plan, Managed Service Organization, IPA. Pay Range : Starting $25 per hour, depending on experience, knowledge, and skills.
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Experience with managed care procedures including PPO network operations, coding and compliance, provider billing/registration/authorization procedures, reimbursement methodologies, claims processing, and revenue management required.
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Minimum 5 years of progressive experience in a health care-related organization is required, with experience in Provider Networks, Contracting, Claims Processing or Managed Care.
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Extensive knowledge of claims reimbursement and insurance collection practices (for Managed Care, Medicare/Medicaid, Workers Comp, etc.) Duties include preparing and processing claims, clearing billing edits, claim validation and submittal, and receivable follow up (e.g. collections, payment review, denials management), and where applicable transfer of charges, record maintenance, ensuring accurate registration, and maintaining applicable documentation.
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Managed Care, Patient Financial services, health insurance claims processing, contract management, or medical economics required. + Proficiency in understanding professional and facility claims and managed care concepts such as risk adjustment, capitation, FFS, DRG, APG, APCs and other payment mechanisms.
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Minimum of five years in a managed care claims processing environment processing all claim types (e.g., inpatient, outpatient, professional, SNF, DME, Home Health, COB) required.
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Abstract information from Medical Records of Managed Care claims for accurate discharge status information on all managed care claims. Research medical records for post-acute care, and verify of accurate discharge status information.
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claims processing managed care jobs
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