Claims Specialist-4

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Process complex claims as assigned by supervisor:
• Fully research and resolve all complex issues and problem codes so claim can properly adjudicate.
• Manually apply specific product or benefit rules to claim for adjudication.
• Ensure claim payment is updated to correctly reflect Point32Health’s status as primary or secondary payer through the appropriate coordination of benefits.
• Determine member’s eligibility if in question.
• Check to determine if services rendered on the claim are allowable under the members benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
• Manually calculate and/or apply pricing to each claim when necessary.
• Process complex claims adjustments as assigned by supervisor:
• Review complex adjustment request to determine if re-adjudication of claim is required.
• Research provider payment inquires related to pricing edits, contract pricing and/or medical coding.
• Examine claim to correct and/or update data so claim can properly re-adjudicate.
• Prepare and enter adjustment while applying appropriate back out and adjustment reason codes.
• While processing claim adjustment, ensure that claims maintains or is appropriately updated to
  • Correctly reflect Point32Health’s status as primary or secondary payer through the appropriate coordination of benefits.
  • Member’s was eligible on DOS.
  • Services rendered on the claim are allowable under the members benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
  • Reflect correct pricing, which may need to be applied or manually re-calculated.
  • Reflect specific product or employer group benefit rules.
• Assist partner departments by providing support on complex claims adjustment issues.
• Promptly research and resolve escalated issues from other departments and/or Management Team.
• Quality & Production:
  • Achieve individual standards for quality and production as assigned by supervisor.
  • Monitor pending claims and adjustments daily and ensure claims are released timely for adjudication.
  • Contribute to team and departmental standards for quality and production.
• Participate in identifying opportunities for overall process improvements.
• Other:
• Serve as SME for documentation, projects and testing.
• Assist partner departments by providing support on complex claims and adjustment issues.
• Communicate (verbally or written) with partner departments to answer and resolve questions.
• Responsible for the timely and accurate processing of Member Reimbursements
• Act as role model and mentor to core claims processors.
• Participate in initiatives or provide back up support to other areas of department as requested.
• Participate in staff & individual meetings and training sessions as required.
• Comply with all department and company guidelines and policies.
• Other duties as assigned

Qualifications – what you need to perform the job

Education, Certification and Licensure

• Required: High school or equivalent education
• Preferred: Associate’s degree or equivalent business experience in a claims/customer service healthcare environment.

Experience (minimum years required):

• Required: 2-4 years experience as a Point32Health Core Claims Processor or similar claims processing or customer service experience required
• Preferred: Working knowledge of Microsoft Office applications and internet navigation is preferred. Experience with Point32Health’s internal applications, such as Diamond, Macess, and Webchannels preferred. Understanding of managed care concepts and a strong understanding of CPT, ICD-9 (ICD-10), HCPCS coding guidelines and CMS1500 & UB04 billing forms preferred.

Additional Skills/Qualifications:

• Knowledge of the rules and regulations governing Coordination of Benefits (COB) and Third-Party Liability (TPL) claims.
• Comprehensive understanding of the National Association of Insurance Commissioners (NAIC) COB rules and guidelines.
• Knowledge of healthcare compliance and relevant regulations, including HIPAA, Medicare, and Medicaid guidelines in COB and TPL processes.
• Proficiency in identifying errors, overpayments, and underpayments, and taking corrective actions.
• Efficiently managing time to handle multiple claims and tasks.
• Ability to analyze complex claims, identify root causes of issues, and develop effective solutions.
• Expertise in resolving claims issues, including denials and coordination of benefits discrepancies.

Skill Requirements

• Position requires strong problem solving and analytical skills with the ability to multi-task.
• Must be able to work independently and as a part of a team.
• Advanced verbal and written skills to communicate internally and externally

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact [email protected]