SENIOR CLAIMS EXAMINER OF GOVERNMENT PROGRAMS
The current healthcare landscape is ever-changing, but the desire to provide patients with better, more affordable care is consistent. Healthcare providers are working to evolve and support population health management and today’s value models, but there is still uncertainty in the market. Providers need a proven, integrated approach that takes the best of today’s technology and matches it with deeply experienced professionals.
Innovista Health Solutions is an Illinois-based service organization with management services operations in Illinois and Texas. We are currently looking for a Senior Claims Examiner of Government Programs in our Oak Brook, IL office. At Innovista, we believe that positive forward movement in today’s uncertain healthcare market stems from the combination of innovative programs and dedicated people. Join the Innovista team and lead the charge to a better, more efficient healthcare system.
Analyze claims and approve or deny payment. Provide expertise on claims processing issues to co-workers and management, particularly as it pertains to government programs.
DUTIES AND RESPONSIBILITIES:
- Approve or deny claims for payment by ensuring the payment is correct, verifying the proper authorizations were submitted, and resolving any system hold codes.
- Resolve reoccurring provider or member issues by identifying trends and recommending solutions to management.
- Capture COB savings by coordinating payments of claims between insurance companies when more than one insurance company is involved.
- Resolve claims issues received from the Customer Services department by researching claim situations and providing timely responses.
- Enhance department productivity by recommending improvements to work flow processes and organizational structure.
- Ensure the completeness and accuracy of Standard operating procedures by providing feedback to the department manager on procedures that require documentation or additional detail.
- Contribute to team effort by accomplishing the related goals and results as determined by the Claim Manager.
- Maintains all necessary levels of member/patient privacy in accordance with HIPAA standards.
- Assist in the implementation of policy development and maintenance for government programs.
- Manage, implement, modify and/or develop processes pertaining to claims payment in existing or new software components.
- Maintain current updates of all external pricing tools.
- Assist with pre-check run audits for government programs.
- Keep current on changing regulatory requirements and ensure that internal software, policies and staff training are updated to maintain compliance.
- Train other staff on government program guidelines, as required.
- Complete reporting requirements exclusive to government contracts, as required.
- Assist with health plan claim audits, particularly involving government programs.
- Process all provider appeals for government programs.
- Process all correspondence, such as delay letters, for government programs, as required.
- Maintain quality levels in compliance with guidelines established for government programs.
- Perform other duties as assigned
- Bachelor’s degree or equivalent experience required
- At least 4-5 years of relevant professional experience, including claims processing for government contracts.
- Knowledge of claims, and processes in a Commercial, Medicare, and Medicaid health plan/TPA organization.
- Extensive knowledge of CPT 4, HCPCS and ICD-10 coding.
- Knowledge of Medical terminology J7J9J2:J6
- Knowledge of government contract guidelines and processes.
- Demonstrate excellent organizational skills.
- Demonstrate effective verbal and written communication skills.
- Demonstrate analytic skills when problem solving.
- Proficient in MS Office Applications and ability to learn department and job specific software systems.
- Demonstrate high attention to detail and a high degree of accuracy
- Able to commit to Innovista’s corporate mission and values
- Able to switch priorities in a positive and effective manner when directed by Company leadership.
- Able to effectively communicate technical concepts with team members and basic business concepts with team members and internal customers.
- Must be comfortable working with and troubleshooting the Microsoft and Mac OS operating systems.
- Eligible for consideration of partial work from home status upon completion of probationary period as designated by the direct supervisor.
Innovista is dedicated to hiring passionate individuals who embody our core values: integrity, determination, and teamwork. We recognize the importance of work-life integration and seek to provide our employees with competitive benefits, which include:
- Comprehensive health plan options, dental, and vision coverage subsidized by Innovista
- Opportunity to work from home, based on position and manager discretion
- Company-paid benefits, such as short- and long-term disability, employee life, and AD&D
- Discretionary bonus
- 401(k) with company match
- Opportunity for career advancement and growth
- Flex time options may be available
This job is posted on Indeed and no other sites. We do not post salary ranges. Salary ranges posted on other sites are not tied to our labor market specifications and are not relevant.
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Job Type: Full-time
- CPT 4, HCPCS, and ICD-10 coding: 1 year (Preferred)
- Claims Processing: 1 year (Preferred)