Data Analyst

Confidenital

• Contacts payers via website, phone and/or written correspondence regarding reimbursement for unpaid appeals over thirty 30 days or more, by researching and following up on denials and requests for additional information
• Establishes and maintains business relationships with case managers, provider relations, and hospital liaisons
• Prepares reports which track trends, costs, and appeal issues and submits to upper management
• Maintains relationship with all Medicaid and Medicare vendors Delmarva, Novitas, and DHMH
• Assists Appeal Coordinators with complex cases
• Enters and reviews Encounter Data into hospital systems after communicating with insurance companies
• Reviews patient benefit information ensuring proper payment for co-pays and deductibles
• Provides training to new employees and refresher courses for current employees
• Assists Operations Manager with the development of Standard Operation Procedures
• Knowledgeable with commercial, Medicaid, and Medicare plans
• Verifies that all appeals are sent in a timely manner to ensure payment ALJ's, Clinical, authorization, Administrative, etc.

Data Analyst/ Appeals Coordinator

Confidenital

• Assures appropriate information was received to initiate the process for reviewing of appeals
• Confirm cases meet criteria for appeal level reviews and assure appropriate information was received to initiate the process
• Research and respond to appeals, complaints, and grievances through several platforms i.e. email, inbound calls, website from providers regarding claim and appeal administration
• Analyze and resolve administrative appeal expedited, pre-service requests through review of benefit design, eligibility, care advocacy procedures, and claims payments as they relate to identified issues
• Coordinates the resolution of appeals related to authorizations and claims and ensure that responses and appeal resolution time frames meet specific client performance guarantees, state requirements, and corporate guidelines
• Prepares communications and notify providers of the appeal determination
• Prepares daily reports which track trends, costs, and determination status of appeals and submits to upper management
• Performs provider credentialing and re-credentialing, and delegated provider credentialing for assigned Health Plan s
• Communicates with physicians and their office staff, hospitals and other provider organizations to provide primary source verification
• Serves as second level Provider Relations support in regards to denied claims, appeals, and credentialing
• Maintains use of the Maryland Electronic Verification Systems to verify Medicaid eligibility for all members during the appeals process
• Assists 3rd party administration with claim configuration to alleviate claims processing errors
• Creates SOP's Standard Operating Procedures to ensure that processes are up to date and adhered to

Senior Data Analyst

Confidenital

• Process requests for data by adding and correcting entries into a specific database or computer application
• Functions as lead to Data Analyst team for national Re-contracting project
• Manually prepares and sends contracts for providers adhering to state requirements and corporate guidelines
• Enters data and source documents monitors to completion
• Compiles, sorts, interprets and verifies data to be entered.
• Communicates with provider offices to resolve questions, inconsistencies or missing data.
• Reviews error reports and enters corrections in system. Files and routes source documents after entry as appropriate.
• Responds to inquiries regarding entered data.
• Trains new Contractors on National Recontracting project
• Assists the Provider Operations Department in maintaining data by using Time Sharing Options Systems
• Assists Database Analyst with special projects within the Access Database
• Creates ad-hoc reports within Salesforce cloud storing systems to assist with data analysis
• Prepares daily reports which track averages, totals, and status of received contracts and submits to upper management

Medicaid and Non-Medicaid Reimbursement Specialist

Confidenital

• Contacts payers via website, phone and/or written correspondence regarding reimbursement for unpaid accounts over thirty 30 days or more, by researching and following up on denials and requests for additional information
• Reports overpayments, underpayments, and other irregularities to insurance companies due to compliance and HIPPA laws and submits adjustment and refunds if necessary
• Reviews settled and paid insurance claims to determine that payments and settlements have been made in accordance with company practices and procedures.
• Provides monthly and weekly reports about insurance analysis, expected collections, and cash collection analysis, amongst others
• Reviews national and local contracting to ensure proper billing and payment procedure
• Maintains knowledge of current practices in healthcare policies/benefits, workman's compensation, long term care security and Medicaid benefits
• Submits appeals to health insurance companies to dispute the validity of claim reimbursement
• Interacts with customers to provide information in response to inquiries about home health services and to resolve complaints
• Oversees the Accounts Receivables and billing for the largest office in District 2 in Georgia
• Verifies healthcare benefits and authorization information for new and existing patients
• Reviews edits, and posts all privately paid or insurance charges transmitted to corporate on a weekly basis
• Reviews patient benefit information ensuring proper payment for co-pays and deductibles
• Acts as a Liaison between the customer and the health insurance company
• Establishes and maintains business relationships with case managers, adjusters, and patients

Senior Data Entry Operator

Confidenital

• Data enters detail from the referral form, including accurate coding of data
• Collectively assists all areas within the company with referral issues, including service request priorities and implied referrals
• Oversees the completion and distribution of work in the claims/referral department when supervisor is away
• Reviews and priced Magellan claims and is responsible in routing to the proper department
• Completes authorizations for claim examiners
• Analyzes and researches referrals, claims adjudication, benefits, and eligibility status
• Maintains familiarity with Current Procedural CPT Codes
• Completes and distributes provider relation reports
• Adjusts inpatient provider claims through the WIN system
• Establishes and maintains business relationships with case managers and nurses internally and externally
• Updates inpatient authorizations