Vacancy caducado!
Note, remote role with a quarterly/ad-hoc onsite requirement in Brooklyn, Ohio. Ohio candidates preferred.Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.ResponsibilitiesClaims Payment Reviewer IReviews or audits routine to moderately complex claims on a pre and/or post-pay basis. As assigned, identifies duplicate or other incorrect payments and researches historical information to determine source/reason for error and adjusts claims according to policies/procedures and regulatory guidelines. As assigned, performs recovery efforts for duplicate or incorrectly paid claims. Responds to incoming telephone and written inquiries, working with internal/external contacts to ensure prompt and accurate claim resolution.· Performs routine to moderately complex recovery/collection on paid claims to provide reimbursement to accounts and ensures precise reporting and history maintenance. Researches and analyzes departmental and membership data/files to determine appropriate action for overpayments received from providers, subscribers and external vendors.· Works with internal departments as well as external contacts to keep abreast of changes (procedural/reporting/systems) and to ensure claims are processed or adjusted in an accurate and timely manner, answering customer inquiries until resolution.· Answers customer service department phone calls related to Refund Request Worksheets generated corporately.· Initiates potential recovery opportunities identified through research and analysis working with department Reporting Analyst.· Performs research and analysis of history to determine root cause of overpayments.· Performs other duties as assigned.Claims Payment Reviewer IIReviews or audits moderately complex to complex claims on a pre and/or post-pay basis and authorizes for release, utilizing various auditing techniques. As assigned, identifies duplicate or other incorrect payments and researches historical information to determine source/reason for error and adjusts claims according to policies/procedures and regulatory guidelines. As assigned, performs recovery efforts for duplicate or incorrectly paid claims. Ensures that systems and procedures have necessary internal controls for proper adjudication and formulates recommendations where controls are inadequate or lacking.· Reviews claims payments and/or performs moderately complex to complex audits and adjustments within scope of authority.· Works with internal departments as well as external contacts to keep abreast of changes (procedural/reporting/systems) and to ensure claims are processed or adjusted in an accurate and timely manner, answering customer inquiries until resolution.· Researches and documents findings and recommendations in audit work applications.· Assists in the development of new and/or modifies existing edits to increase departmental goals/efficiency.· Responds to incoming telephone and written inquiries, working with internal/external contacts to ensure prompt and accurate claim resolution.· Conducts or participates in special audits/projects.· Performs other duties as assigned.Senior Claims Payment ReviewerReviews or audits complex claims on a pre and/or post-pay basis and authorizes for release, utilizing various auditing techniques. Ensures that systems and procedures have necessary internal controls for proper adjudication and formulates recommendations and assists leadership with implementation where controls are inadequate or lacking. Orients, trains and assists more junior level staff.· Reviews claims payments and performs complex audits and adjustments within scope of authority.· Works with internal departments as well as external contacts to keep abreast of changes (procedural/reporting/systems) and to ensure claims are processed or adjusted in an accurate and timely manner, answering customer inquiries until resolution.· Develops new and or modifies existing edits to increase departmental goals/efficiency.· Researches and documents findings and recommendations in audit work applications.· Orients, trains and assists more junior level staff.· Compiles and interprets data and generates database reports, identifies trends or system issues, recommending solutions to management team. Assists supervisor with work distribution, inventory and aging reporting.· Works with leadership to conduct or participate in special audits/projects.· Responds to escalated incoming telephone and written inquiries, working with internal/external contacts to ensure prompt and accurate claim resolution.· Performs other duties as assigned.QualificationsClaims Payment Reviewer I· Bachelors’ Degree in Business or Healthcare Administration or related field preferred, but will consider collective experience, training and education.· 3 years’ experience in health insurance claims processing/customer service, collections or related operations.· Internal operations experience preferred.· Knowledge of claims payment guidelines/procedures/corporate web applications.· Knowledge of medical terminology and coding.· Knowledge of claims adjudication systems. Membership, Medical Review and the National Network System files preferred.· Understanding of how errors impact business operations and relationships between components.· Intermediate Microsoft Office and OnBase skills.Claims Payment Reviewer II· Bachelor’s Degree in Business or Health Care Administration or related field preferred, but will consider collective experience, training and education.· 1 year experience as a Claims Payment Reviewer or equivalent experience in health insurance claims, customer service, auditing, or advanced research.· Internal operations experience preferred.· Certified Medical Audit Specialist (CMAS) preferred.· Solid knowledge of group and hospital contracts and benefits, claims coding, adjustments, suspends and internal claims processing systems.· Strong knowledge of medical terminology and coding.· Thorough understanding of how errors impact business operations and relationships between components .· Thorough knowledge of claims payment auditing guidelines/procedures/corporate web applications.· Knowledge of claims research or auditing techniques.· Knowledge of claims adjudication systems, Membership, Medical Review and the National Network System files.· Intermediate or advanced Microsoft Office and OnBase skills.· Solid database reporting skills. Ability to gather, compile and interpret data to identify patterns and establish relationships.Senior Claims Payment Reviewer· Bachelor’s Degree in Business or Healthcare Administration or related field preferred, but will consider collective experience, training and education.· 2 years’ experience as a Claims Payment Reviewer II or equivalent experience in health insurance claims, customer service, auditing, or advanced research.· Internal operations experience preferred.· Certified Medical Audit Specialist (CMAS) strongly preferred.· Comprehensive knowledge of group and hospital contracts and benefits claims coding, adjustments, suspends and internal claims processing systems.· Complete understanding of how errors impact business operations and relationships between components.· Strong knowledge of claims payment auditing guidelines/procedures/corporate web applications.· Strong knowledge of medical terminology and coding.· Strong knowledge of claims adjudication systems, Membership, Medical Review and the National Network System files.· Strong knowledge of claims research or auditing techniques.· Advanced Microsoft Office and OnBase skills.· Strong database reporting skills. Ability to gather, compile and interpret data to identify patterns and establish relationships.Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:A Great Place to Work:
We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
Discounts at many places in and around town, just for being a Medical Mutual team member.
The opportunity to earn cash rewards for shopping with our customers.
Business casual attire, including jeans.
Excellent Benefits and Compensation:
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
Career development programs and classes.
Mentoring and coaching to help you advance in your career.
Tuition reimbursement up to $5,250 per year, the IRS maximum.
Diverse, inclusive and welcoming culture with Business Resource Groups.
About Medical Mutual:Medical Mutual’s status as a mutual company means we are owned by our policyholders, not stockholders, so we don’t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.There’s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.We’re not just one of the largest health insurance companies based in Ohio, we’re also the longest running. Founded in 1934, we’re proud of our rich history with the communities where we live and work.We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.Title: Claims Payment ReviewerLocation: OhioRequisition ID: 2400050
Vacancy caducado!