Under general supervision, Analyst Business Care Claims is responsible for benefit administration and assist with the daily management of claims inventory. Daily data analysis and research of claims processing to ensure benefit structures and operation processes are adhering to the rules, regulations and contractual requirements by CMS, DOI, contracted and non- contracted providers. Oversee the daily management of claims inventory through Business Management Services (BMS) for issue escalations or resolutions. Serves as liaison between users of the software and technical staff (BMS and IS). Work in conjunction with the Compliance program to monitor and detect potential claims for fraud and abuse.This position will interact will all levels of management and employees.
1. Conduct weekly check run finalizations for all plans based on summary reports to ensure that claim payments are adhering to the rules, regulations and contractual requirements by CMS, DOI, contracted and non-contracted providers.
2. Monitor members out of pocket maximums.
3. Work in conjunction with the Compliance program to monitor and detect potential claims for fraud and abuse. Ensure timely adjustments and/or recoups are completed as a result of corrected claims, pricing eligibility, incorrect coding or duplicate payment.
4. Provide Claims Manager with regular reports and analysis of claims along with aging reports.
5. Ensure timely adjustments are made as a result of audits along with reconciling providers' and vendor's invoices.
6. Oversee the daily management of claims inventory through Business Management Services (BMS) for issue escalation or resolution.
7. Assure through audits, reports and personal contact that the company benefit programs are consistently administered in compliance with company policies and government regulations.
8. Accurately perform audits on claims processed by the BMS and system generated claims. Perform special claims audits as assigned.
9. Perform training to support the implementation of new lines of business, changes to current lines of business or other training as identified by the Product Line Managers.
10. Assist other departments in preparing for Internal/External audits performed by CMS, the State or our independent financial auditors, or other contract holders.
11. Initiate subrogation letters when deemed appropriate.
12. Provides assistance to Member Services, Provider Relations, Finance, Compliance, Utilization Management, IS and Subrogation partner.
13. Perform check run processes for all lines of business, Medicaid, Medicare, Medical Care Group, Point of Service, CHP+, Exchange, and VMO.
14. Review all summary reports and make corrections as needed.
15. Identify trends and provide recommendations for changes and improvements of departmental policies and procedures to the claims team (BMS).
16. Audit the offshore claims processor to maintain quality measures. Daily review of BI Portal reports to ensure claims turnaround time and provide necessary pricing guidelines.
17. Recoups, subrogation, accumulator overages, COB adjustments and other adjustments as defined (TC3). Implement configuration testing and review of system generated compares for new benefits and system enhancements. Continual review and rewrite of current Policy and Procedures.
18. Engage with provider relations to facilitate special manual pricings or one time contracts.
19. Research and coordinate with utilization management for changes in authorization requirements.
20. Investigate billing issues from internal and external vendors.
21. Create and analyze month end reports (IBNR) for Finance.
22. Assist with Policy & Procedure updates.
23. Assist other departments as needed. Design, formulate, and maintain training material for BMS team and other co-workers.
24. Communicate and intervene appropriately with departmental personnel when required or requested to help resolve issues.
25. Other duties as assigned.
Knowledge, Skills and Abilities
1. Thorough knowledge of QNXT and benefit structure to ensure claims accuracy.
2. Ability to define problems, collect data, establish facts and draw valid conclusions.
3. Knowledge of all claim forms and coding types, including UB-04, CMS1500, ICD-9-CM, CPT-4, ICD-10-CM, HCPC, Revenue and NOC coding. HIPPA, HEDIS.
4. Experience with Medicare, Medicaid and Commercial programs preferred.
5. Extensive knowledge of claims administration in a healthcare field.
6. Ability to lead/manage projects and interact with staff on all levels.
7. Able to implement testing material for changes with benefit structures for all lines of business.
8. Interact and collaborate with other corporate groups such as Provider Relations, Member Services, Information Systems, Compliance, Third Party Recovery, Finance, Patient Accounts, Enrollment, Utilization Management and Product Line Managers.
9. Key candidate will be adaptable; detailed oriented and have strong analytical skills.
10. Excellent verbal and written communication skills.
Computers and Technology
1. Access database, Reports, Queue's and other tools as needed.
2. Total Claims Capture and Control (TC3) experience preferred.
3. Working knowledge of CMS/Medicare payment platforms a plus including the Resource Based Relative Value System (RBRVS) and Diagnostic Related Groups (DRG).
4. Proficiency in Word, Excel, Webstrat, PowerPoint, Business Intelligence Portals and Audit Tool.
1. Bachelor's degree and three years relevant experience required OR
2. Associate's degree and six years relevant experience required OR
3. High school diploma/GED and nine years relevant experience required.
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 3666
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.