Job Description

ROLE SUMMARY:

AllyAlign Health (www.allyalign.com) is a rapidly growing organization focused on revolutionizing the long-term healthcare ecosystem for the benefit of our members, provider and payer partners. Our unique approach to managing care delivery and proactively partnering with healthcare providers has enabled us to achieve industry leading health outcomes for our members. AllyAlign Health has partnered with several Nursing Home companies to form Institutional Special Needs Plans (I-SNPS), which are a form of Medicare Advantage Plans.

In this model, AllyAlign is responsible for administering the health plans, providing shared services such as member enrollment, call center, claims processing, authorization processing, financial services, compliance services and grievance and appeals administration. AllyAlign has grown very aggressively and is working to expand our operational capacity and capability.

AllyAlign Health is looking for a qualified candidate to be a key member of our Medicare Advantage Claim Operations team, as our Medicare Claims Examiner. Reporting to the Manager of Claims Operations. This location preference is Glen Allen, VA, or Nashville, TN. We will consider virtual for the right candidate.

JOB SUMMARY:

The Claims Examiner is responsible for the accurate and timely processing Healthcare Claims in compliance with AAH Policies and CMS regulatory guidelines. The desirable candidate is expected to provide courteous and prompt responses to any and all inquiries. The desirable candidate is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.

RESPONSIBILITIES:

• Work to ensure 95% of claims paid within 30 days for OON timeliness
• Adjudicate claims at a rate equal to department goals,
• Maintain statistical and financial accuracy targets for claims processed
• Respond timely to all Customer Service, Provider Relations type questions
• Analyzes and validates pricing
• Adjust claims utilizing current billing code sets, (i.e. ICD-10, CPT, HCPC)
• Corrects system generated error reports prior to final adjudication
• Processes claims based on the provider's contract, contract type and applicable regulatory legislation
• Must have a comprehensive understanding of all Centers for Medicare Services (CMS) compliance standards
• Excellent verbal and communication skills
• Must be able to read and interpret all types of medical claims and medical claim forms
• Must be able to read/interpret and apply member benefit plans and EOCs
• Must be able to identify payor responsibility based on claim type and billed service(s)
• Verifies the accuracy and receipt of all required documentation for each claim submitted.
• Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim.
• Analyzes the information necessary for processing. This includes, but is not limited to, general participant and provider information, diagnosis codes, dates, place, type of service, procedure codes, and charges.
• Assures that the system processes the claim correctly and determines payment according to the plan as written.
• Resolves problematic claims with the assistance of the Team and Claims leadership.
• Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent.
• Aids the Team and/or the Claims Supervisor in the resolution of claim appeals and disputes by providing documentation for review.
• Researches, calculates and requests refunds when necessary.
• Contributes to the daily workflow with regular and punctual attendance.
• Performs related or other assigned duties as required or directed.
• Attends various group meetings as required.
• Assists with audits as needed.

KNOWLEDGE & SKILLS REQUIRED:

• Minimum of 5+ years of experience in Medicare Claims Processing for a Health plan.
• Minimum of High school graduation or GED required.
• College degree and/or training in medical terminology preferred.
• 2+ years of experience with Citra's Ezcap claims platform
• Knowledge of DRG Payment, Grouper/Pricers
• Comprehensive knowledge of all claims, billing and payor resource materials
• Ability to interpret and apply provider and health plan specific contracts and benefit matrices
• Must be able to work in an assigned work queue- working with dashboards and communication modules
• Working knowledge and understanding of healthcare A/R management, bill types, HCFA 1500 and UB04 claim forms, and claim clearinghouse systems.
• Excellent knowledge and understanding of Medicare ICD10, CPT and HCPCS coding.
• Knowledge of patient billing terminology, collections as well as Medicare and Medicare Advantage billing, rules and regulations and compliance.
• Strong understanding of modifiers and Correct Coding Initiative rules.
• Familiarity with Medical Terminology
• Must be quality and process oriented
• Must be able to perform in a high- volume/time sensitive production environment
• Must be PC proficient

BENEFITS:

• Market competitive salary
• Flexible PTO
• 9 Paid Holidays per Year (7 fixed and 2 floating)
• Medical Insurance
• Dental Insurance benefits
• Vision Insurance benefits
• Health Savings Account contributions if you elect to participate in our Medical Insurance plan
• Long-Term Disability / Short-Term Disability and Life Insurance
• 401K Plan