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 & DutiesProcess ClaimsReview, 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 systemReview and analyze received claims to determine accuracy of adjudicationIdentify adjudication errors, provider billing errors, and needs for technical assistanceMonitor adjudication results using provided reportsApply basic claims knowledge in the review of patient and provider accounts to determine if account updates are neededApply knowledge of eligibility, enrollment, prior approval, contracts, and credentialing to identify account needsUsing existing reports, assure claims are processed within prompt payment guidelinesUsing Compliance Unit's reversion packets, process refunds or adjustmentsReview claims for appropriate service event authorizations, consumer eligibility, and routine billing requirementsEnsure appropriate coordination of benefits has occurred utilizing billing and payment policies and proceduresManually process claims unable to be adjudicated properly within MCS; including linking claims that error to the Exceptions ReportMonitor and resolve technical issues within the Claims systemUtilizing existing reports, monitor, track, and resolve Patient Monthly Liability corrections on provider claims and within NCTracksReview policy requirements associated with new or additional services to be processed and apply the knowledge to the processing of associated claimsReporting Utilize reports to identify and resolve claims errors or updatesCreate 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 adjudicationCommunication Communicate and conduct liaison work across multiple departments to resolve claims denials/issuesCommunicate with high level external stakeholders like DHB, DHHS, and DSSCommunicate with internal stakeholders (all departments)Communicate with provider agenciesDemonstrate 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 updatesDevelop training materials to facilitate trainingsAssist with Claims Process Improvement Identify resolution of system errors, review impact reports, communicate with providers and determine steps for reconciliationProvide 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 resultsMaintain processes that are consistent with and compliant to CMS, state, federal and URAC standards, regulations and guidelinesRead, review, analyze, and apply information from published clinical coverage policies and other NCDHHS documents to ensure the claims system and manual processes are incorporating required actionsData Analytics Demonstrate high level understanding of data; effectively utilize data mining tools; build report parametersLeadership Demonstrate leadership abilities through independent work, role modeling for peers, taking initiative with tasks and process improvement activities, engages in all aspects of claims actionsProvide first level consultation to peersSupport Expansion and New Business Learn new skills related to expansion and new business requirements per Alliance Health contracts. This includes coverage of additional catchment areas, new covered services, processing and handling of physical health claimsTechnical Apply claims processing skills. Apply detailed knowledge of how the Alliance Claims System (ACS) works. Identify ACS system issues, create tickets, strategize solutions with IT Development team, track tickets, communicate resolutions to providers. Analyze impact reports and follow resolution efforts through claims reconciliationMinimum RequirementsEducation & ExperienceHigh School degree or equivalent and four (4) years of related experience (in customer service, claims processing, research/analytics, or communications);OrBachelor's degree from an accredited college or university in related field and two (2) years of experience (in customer service, claims processing, research/analytics, or communications).Preferred:Experience with Medicaid and IPRS preferred.Knowledge, Skills, & AbilitiesKnowledge of Microsoft Office, including Excel, Word, OutlookWorking knowledge of healthcare services and systemsWorking knowledge of functions provided by Provider Networks, Utilization Management, Accounts Payable, Contracts, and Care ManagementKnowledge of common claims denials and sources for correctionKnowledge of Medicaid and IPRS rulesKnowledge of laws, legal codes, precedents, government regulations, and MCO policies and proceduresKnowledge of medical terminology, CPT/HCPCS/UB04 revenue coding, modifiers, and billing regulationsExcellent customer service skillsProficiency in written and oral communication sufficient for the sharing of technical informationStrong organizational skillsAbility to set objectives and prioritize workflowAbility to document clearly and accuratelyAbility to solicit cooperation from persons and departments throughout the organizationAbility to adhere to department policies, procedures, and general practicesAbility to work independently and as part of a teamAbility to demonstrate professional conduct in all situationsAbility to take initiativeAbility to solve complex problems through the evaluation of alternative methods and solutionsAbility to develop strong working relationships with divergent groups and communicate technical concepts to lay personsAbility to utilize efficient practices to complete assigned workloadAbility to demonstrate professional presentation and conduct at all timesAbility to independently follow instructions or desk procedures accurately and without error Salary Range$22.90 - $29.19/hourlyExact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.An excellent fringe benefit package accompanies the salary, which includes:Medical, Dental, Vision, Life, Long Term DisabilityGenerous retirement savings planFlexible work schedules including hybrid/remote optionsPaid time off including vacation, sick leave, holiday, management leaveDress flexibilityEqual Opportunity EmployerThis employer is required to notify all applicants of their rights pursuant to federal employment laws.