Louisiana Staffing
Job Summary
Highmark Inc. is responsible for assisting in the processing and investigation of non-complex health care claims to determine the legitimacy of claim charges. The incumbent will also conduct or assist with provider and subscriber investigations to verify the validity of services and charges; will monitor internal referrals from sources such as claims, customer service, Medicare C&D Compliance, and Fraud Hotlines; will alert Investigators of the need for further analysis; will perform claims system extracts and create reports, graphs and charts to support case documentation; will prepare necessary correspondence to set and monitor provider and member claim system flags; will work with external vendors to recover confirmed over payments, coordinate payment of vendor invoices and coordinate request for an independent review determination; will participate in various internal committees as assigned; will update departmental tracking logs such as consultant listings, provider/member flag tracker and certified mail; and will input and maintain current case information in applicable case management tracking systems. Essential Responsibilities
Claims Reviews/Investigation: Arrange for collection of claims and supporting data from internal and external sources including providers, customers and accounts; Review claims and supporting documentation to verify the legitimacy of medical and drug claim charges; Work with external vendors to recover confirmed facility and professional provider over-payments. Investigation Support: Assist with investigations: Assist in the interviews of customers and providers to obtain information in suspected fraud waste and abuse cases; Prepare reports and other information to document audit findings. Calculate over-payments in established fraud, waste and abuse cases. Identify all suspect activity included in the case, determine what lines of business were involved in the suspect activity, and measure over-payment by means of sampling or complete review. Data Analysis: Perform claims system extracts and create reports, graphs, and charts to support case documentation; Review reports and other information to identify claims and related documents requiring investigations based on pre-determined criteria, including review of suspect claims, Fraud Hot Line and internal referrals. Update departmental tracking logs such as consultant listings, provider/member flag tracking, record request tracking, vendor related, certified mail, etc. Maintain current case related information on all applicable case management tracking systems. Set and update member flags and monitor claims that suspend due to the flag. Other duties as assigned or requested. Education
Required: Associate's Degree. Substitutions: 3 years of related and progressive experience in lieu of Associate's degree. Preferred: None. Experience
Required: 3 years in Healthcare, Finance, provider office or related industry. Preferred: Experience in processing Blue Card, Local and FEP claims; Experience in working with SAS. Licenses or Certifications
Required: None. Preferred: Certified Professional Coder (CPC). Skills
Demonstrated proficiency in using Excel and Word; Knowledge of medical terminology; Demonstrated strong multi-tasking and organizational skills; Demonstrated strong verbal and written communication skills; Demonstrated proficiency in using OSCAR, INSINQ, ICIS, and COR or experience with other claims related processing platforms. 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 Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely. 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 Companys Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employees responsibility to comply with the companys 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: $21.53 Maximum: $32.30 Base pay is determined by a variety of factors including a candidates 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. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org. California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J269756
Highmark Inc. is responsible for assisting in the processing and investigation of non-complex health care claims to determine the legitimacy of claim charges. The incumbent will also conduct or assist with provider and subscriber investigations to verify the validity of services and charges; will monitor internal referrals from sources such as claims, customer service, Medicare C&D Compliance, and Fraud Hotlines; will alert Investigators of the need for further analysis; will perform claims system extracts and create reports, graphs and charts to support case documentation; will prepare necessary correspondence to set and monitor provider and member claim system flags; will work with external vendors to recover confirmed over payments, coordinate payment of vendor invoices and coordinate request for an independent review determination; will participate in various internal committees as assigned; will update departmental tracking logs such as consultant listings, provider/member flag tracker and certified mail; and will input and maintain current case information in applicable case management tracking systems. Essential Responsibilities
Claims Reviews/Investigation: Arrange for collection of claims and supporting data from internal and external sources including providers, customers and accounts; Review claims and supporting documentation to verify the legitimacy of medical and drug claim charges; Work with external vendors to recover confirmed facility and professional provider over-payments. Investigation Support: Assist with investigations: Assist in the interviews of customers and providers to obtain information in suspected fraud waste and abuse cases; Prepare reports and other information to document audit findings. Calculate over-payments in established fraud, waste and abuse cases. Identify all suspect activity included in the case, determine what lines of business were involved in the suspect activity, and measure over-payment by means of sampling or complete review. Data Analysis: Perform claims system extracts and create reports, graphs, and charts to support case documentation; Review reports and other information to identify claims and related documents requiring investigations based on pre-determined criteria, including review of suspect claims, Fraud Hot Line and internal referrals. Update departmental tracking logs such as consultant listings, provider/member flag tracking, record request tracking, vendor related, certified mail, etc. Maintain current case related information on all applicable case management tracking systems. Set and update member flags and monitor claims that suspend due to the flag. Other duties as assigned or requested. Education
Required: Associate's Degree. Substitutions: 3 years of related and progressive experience in lieu of Associate's degree. Preferred: None. Experience
Required: 3 years in Healthcare, Finance, provider office or related industry. Preferred: Experience in processing Blue Card, Local and FEP claims; Experience in working with SAS. Licenses or Certifications
Required: None. Preferred: Certified Professional Coder (CPC). Skills
Demonstrated proficiency in using Excel and Word; Knowledge of medical terminology; Demonstrated strong multi-tasking and organizational skills; Demonstrated strong verbal and written communication skills; Demonstrated proficiency in using OSCAR, INSINQ, ICIS, and COR or experience with other claims related processing platforms. 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 Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely. 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 Companys Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employees responsibility to comply with the companys 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: $21.53 Maximum: $32.30 Base pay is determined by a variety of factors including a candidates 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. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org. California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J269756