Job Description

Company :

Highmark Inc.

This job ensures that services provided to health plan members and billed by providers to the health plan are submitted to respective State agencies and CMS accurately and timely. Ensures accuracy of complex data with minimal errors to further ensure that health plan medical expense on file at respective State and CMS is complete and up to date.Completes complex root cause analysis and research of errors to generate corrections in a timely manner to provide an accurate picture of medical expense and avoid penalties from the State and/or CMS.Provides guidance and education to lower level employees.

This is a remote based role however will need to go onsite 1 day a month.

ESSENTIAL RESPONSIBILITIES

• Actively participate in decision making process and documentation for meeting Service Level Agreements (SLA) set by respective states of operation
• Lead regular meetings with Internal and External Clients/Vendors to review projects globally, coordinate collaborative efforts and knowledge sharing among all team members, seeking opportunities to leverage existing processes.
• Analyze and research complex encounter errors to identify root cause(s) and make recommendations for resolution.
• Research and document all encounter errors in established database(s).
• Communicate regularly with management on issues discovered through research efforts.
• Communicate with and provide clear, detailed, effective documentation to other departments within the organization on issues causing encounter pends/denials and potential solutions.
• Handle reversals / recoupments resulting from encounter errors.
• Produce monthly summary reports identifying adjudication errors.
• Other duties as assigned or requested.

EDUCATION

Required

• High School Diploma/GED

Substitutions

• None

Preferred

• B achelor’s in healthcare analytics or related field

EXPERIENCE

Required

• 5 - 7 years in Encounters, Claims Processing or Claims Billing

Preferred

• SQL and SAS experience.

• 5-7 years in Encounter data management, claims/billing, healthcare analytics or related field.

LICENSES AND CERTIFICATIONS

Required

• None

Preferred

• None

SKILLS

• Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
• Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
• Demonstrated organizational skills
• Ability to work independently
• Ability to work as part of a team
• Ability to work in a fast paced environment with changing priorities
• Demonstrated written communication skills
• Demonstrated interpersonal/verbal communication skills
• Demonstrated research skills
• Demonstrated detail orientation
• Understanding of AHCCCS and CMS rules/regulations including encounter process
• Health/Medical Programs
• HIPAA
• Outlook
• Microsoft Office
• Microsoft Excel

Language (Other than English)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Frequently

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements

Pay Range Minimum:

$72,700.00

Pay Range Maximum:

$116,600.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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