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Responsibilities : Develop business requirements for the claim processing system, as well as claims adjudication instructions based on analysis of administrative and medical policy requirements. Conduct training on these instructions for Benefit Examiners in Senior Plans unit, private business units and for other HMSA departments as needed. Communicate results of analysis and training to internal customers including but not limited to private business units, Utilization Review, Provider Services, Customer Service, Marketing, and Underwriting. Methods of communication can include but are not limited to memos, letters, training documents, claim filing instructions and suspend error resolutions (pricing instructions). Communicate results of analysis and training for a specific case to external customers such as an individual member or provider. Identify and analyze provider claim billing issues and trends as a result of the claims review. Develop clear, concise documentation, which describes the business trend or issue. This documentation will be used to develop medical and reimbursement policies and may also be used as the basis for executive summaries. Provide recommendations to management based on analysis performed. Develop and implement workflows with and outside the Unit based on specific business or program requirements. technical resources to improve operational performance relating to claims processing productivity and accuracy. Release claims for the Senior Plans unit using all automated and manual transactions. Perform adjustments for claims and inquiries reviewed by the Senior Plans unit. Participate in internal and external auditing activities. Respond to complex and /or sensitive issues with discretion and judgment using a variety of methods with limited or no direction. Attend and successfully complete and Medicare training as directed by supervisor. Perform other duties as assigned.

Requirements :Bachelors degree from college or university in communications, statistics, English, business administration or one year related experience and/or training in healthcare field, preferably with the Medicare program; or equivalent combination of education and experience. Effective analytical skills.

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Published at 26-02-2010
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