Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.
Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.
Claims Investigation Analyst
•Review internal and external provider claim inquiries and perform root cause analysis around possible causes of claim issues. This may include contract implementation, fee scheduled development, prior authorizations, provider billing inconsistencies, etc.
•Assess the need for claim adjustments and/or Provider education.
•Process provider correspondence efficiently while adhering to timelines and guidelines utilizing independent decision making skills as appropriate.
•Tracking adjustment requests and validating adjustment outcomes are in line with Provider expectations.
•Demonstrate great depth of knowledge surround claims processing, specifically Medicare/Medicaid
•Act as a technical resource to others in the organization
•Proactively identify solutions to non-standard requests
•Resolving complex claims issues independently and with minimal direction
•Work with teams to solve complex problems
•Plan, prioritize, organize and complete work to meet established objectives
•May coordinate work of other team members
• Intermediate MS Excel experience intermediate knowledge of Microsoft Excel. This includes the ability to create and build spreadsheets with formulas and advanced function capabilities
• Intermediate knowledge of Microsoft PowerPoint and Microsoft Word. This includes the ability to create slide presentations for the purposes of delivering training in a group setting
• Proven industry knowledge and continuous learning and development in this field
• In-depth experience and knowledge of industry standard claims processing policies and procedures
• Negotiation and conflict resolution skills
• Excellent verbal and written communications skills are essential.
• Candidate must be able to prioritize work and use independent judgment
Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws