Job Description

At Brighton Health Plan Solutions (BHPS), we're creating something new and different in health care, and we'd love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers - and that's why we're creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we're fiercely committed to positively impacting our partners. Company Mission: Transform the health plan experience - how health care is accessed and delivered - by bringing outstanding products and services to our partners. Company Vision: Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. About this Role: BHPS is seeking an experienced Healthcare Claims Examiner skilled in the interpretation of Hospital and Ancillary contracts, Medical Policies and Payment procedures as well as capable of manually processing claims according to all outlined Policies and Procedures. Primary Responsibilities: * Research and document pertinent information on claims requiring adjudication. Apply medical policy, contractual provisions and operational procedures to ensure accurate adjudication and/or adjustment * Reprice Workers' Comp and No Fault claims while adhering to the specified turnaround times * Perform quality review of claims and logic changes/updates in Impact * Authorizes generation of letters/questionnaires, etc. to customers and providers to obtain additional information; may initiate telephone inquiries * Assist Customer Service in responding to and resolving customer questions and concerns * Performs various other duties as required * Provide support to the Client Services department; research and resolve client inquiries * Perform client requested claim adjustments; provide clear and concise written responses to each client inquiry within the specified timeframes * Perform thorough research of ARs and Spreadsheets requiring claim adjustments, research and clarifying responses to providers and/or clients * Research Medicaid Recovery demand letters and compile a thorough and detailed response Essential Qualifications: * Strong knowledge of contracts, medical terminology, and claims processing and procedures * 1+ year computer medical billing or claims adjudication systems experience * Excellent written and oral communication, interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required * Ability to meet expected production standards * Proficient in Microsoft Office Suite- specifically Microsoft Word and Microsoft Excel * Ability to maintain a professional demeanor under pressure * Capable of managing multiple complex issues * Strong knowledge of contracts, medical terminology, and claims processing and procedures * High School Diploma or GED diploma; some college or business school education is a plus *We are an Equal Opportunity Employer Company Description Brighton Health Plan Solutions Company Mission: Transform the health plan experience - how health care is accessed and delivered - by bringing outstanding products and services to our partners Company Vision: Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways

Company Description

Brighton Health Plan Solutions\r\n\r\nCompany Mission:\r\nTransform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners\r\nCompany Vision: \r\nRedefine health care quality and value by aligning the incentives of our partners in powerful and unique ways