The Senior Claims Analyst may be a remote (work from home) position but you must have experience with QNXT and it must be in your resume in order to be considered.
Although this is remote you must live in the greater Los Angeles - Long Beach area.
Morgan Stephens represents the nation’s top healthcare systems offering the highest compensation and benefits to our top candidates. We are created and managed by experienced industry professionals in healthcare. As a leading provider of contract, contract to perm, and direct placement recruiting services to healthcare organizations throughout the United States, we have successfully served the needs of our employees and clients by placing thousands of quality healthcare professionals into organizations seeking top talent.
We are seeking a Senior Claims Analyst.
• Analyze and research claim disputes to determine the decision, including underpayment, overpayment, correct denial, incorrect denial, etc. to correctly reimburse the claim based on contractual or non-contractual reimbursement.
• Conducting claim research, identify and resolving issue.
• Update created case in the system to document the claim research findings and decisions.
• Examine the claim with evidence and determine the validity of the claim against the billing requirements from both CMS and CA DHCS (CMS and CA Medi-Cal billing requirements).
• Systematically triage claims through built-in workflow that require Medical Necessity review to Post-Service clinical team for medical record review and decision.
• Systematically triage claims through built-in workflow that require investigation on specific claims edit to Code Edit team for confirmation and decision.
• Systematically triage claims through built-in workflow that require adjustment to the claim.
• Send formalized Resolution letter with claim research decision to the provider within required turnaround time.
• Use WebStrat to determine DRG pricing
• Must be comfortable working in production driven environment with expected daily production volume and standards.
• Must be experienced in QNXT System to research and review how claim was adjudicated and reimbursed.
• Must be experience in FFS claim reimbursement from a managed care health plan (as the payer).
• Must know CMS and CA Medi-Cal billing requirements and know how to gather evidence from these regulatory sources.
• Minimum of 3 years of experience related to claims processing, billing, adjustment, claims research, and dispute resolution
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