1199SEIU Funds
Coordinator
Responsibilities Ensure timely/accurate processing of hospital claims at the coordinator dollar-level, correspondence, and call tracking tickets according to 1199 Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters, coordination of benefits (COB), regulatory and pre-authorization requirements, Medicare National Correct Coding Initiative (NCCI) rules, provider, repricing network contract terms and timeframes, fund and departmental policies Resolve complex claim issues involving: 1st, 2nd, and 3rd level (IPRO) appeals; foreign claims; spreadsheet projects; reconsiderations; inquiries; adjustments; pending reports/DMS queues; medical records; email communications; MedReview and Diagnostic Related Group determinations. Coordinate with QNXT Production Support, Provider Relations, Eligibility, Care Management, Liens, Member Services, and Outreach where necessary Provide quality assurance and technical support of hospital claims processing; analyze discrepancies between executed contracts and QNXT system pricing, to ensure appropriate rates, groupers, and attributes are loaded for adjudication Conduct system testing related to QNXT upgrades, system enhancements, and external vendor processes Act as liaison between fund and external vendors (i.e. ExpressScripts/CareContinuum, Evicore) to resolve authorization and unit reduction issues Process all aspects of Medicare Secondary Payer (MSP) claims: to include adjudication of claims, and creating correspondence in response to Medicare third-party agencies Review hospital claims reports for duplicates, auto-adjust authorization download issues that require intervention as a result of system limitations and manual workarounds Analyze overpayment and unsolicited refund data from the Claims Recovery unit to determine trends, identify system issues and payer errors; make recommendations for mitigation/process improvement Assist management in optimizing workflows, auditing of staff, providing checks and balances for strategic reports and in making recommendations to assist in coaching and mentoring opportunities Perform additional duties and projects as assigned by management Qualifications Bachelor's degree in Business, Healthcare or Public Health Administration preferred, or equivalent years of experience Minimum three (3) years experience working in hospital claims processing, claims auditing, or quality assurance Strong organizational, analytical, problem-solving, critical thinking and time management skills Demonstrated ability to efficiently manage multiple projects, work well under pressure, establish priorities, meet deadlines, and follow through on assignments Excellent knowledge of CPT, ICD-10, HCPCS codes; UB-04 fields; claims reimbursement methodologies; ability to read/navigate QNXT and Vitech systems; intermediate knowledge of Microsoft Word and Excel Strong knowledge of Coordination of Benefits (COB) and Medicare Secondary Payor regulations Effective oral/written communication; demonstrated ability lead/motivate others; work in a collaborative team environment
Responsibilities Ensure timely/accurate processing of hospital claims at the coordinator dollar-level, correspondence, and call tracking tickets according to 1199 Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters, coordination of benefits (COB), regulatory and pre-authorization requirements, Medicare National Correct Coding Initiative (NCCI) rules, provider, repricing network contract terms and timeframes, fund and departmental policies Resolve complex claim issues involving: 1st, 2nd, and 3rd level (IPRO) appeals; foreign claims; spreadsheet projects; reconsiderations; inquiries; adjustments; pending reports/DMS queues; medical records; email communications; MedReview and Diagnostic Related Group determinations. Coordinate with QNXT Production Support, Provider Relations, Eligibility, Care Management, Liens, Member Services, and Outreach where necessary Provide quality assurance and technical support of hospital claims processing; analyze discrepancies between executed contracts and QNXT system pricing, to ensure appropriate rates, groupers, and attributes are loaded for adjudication Conduct system testing related to QNXT upgrades, system enhancements, and external vendor processes Act as liaison between fund and external vendors (i.e. ExpressScripts/CareContinuum, Evicore) to resolve authorization and unit reduction issues Process all aspects of Medicare Secondary Payer (MSP) claims: to include adjudication of claims, and creating correspondence in response to Medicare third-party agencies Review hospital claims reports for duplicates, auto-adjust authorization download issues that require intervention as a result of system limitations and manual workarounds Analyze overpayment and unsolicited refund data from the Claims Recovery unit to determine trends, identify system issues and payer errors; make recommendations for mitigation/process improvement Assist management in optimizing workflows, auditing of staff, providing checks and balances for strategic reports and in making recommendations to assist in coaching and mentoring opportunities Perform additional duties and projects as assigned by management Qualifications Bachelor's degree in Business, Healthcare or Public Health Administration preferred, or equivalent years of experience Minimum three (3) years experience working in hospital claims processing, claims auditing, or quality assurance Strong organizational, analytical, problem-solving, critical thinking and time management skills Demonstrated ability to efficiently manage multiple projects, work well under pressure, establish priorities, meet deadlines, and follow through on assignments Excellent knowledge of CPT, ICD-10, HCPCS codes; UB-04 fields; claims reimbursement methodologies; ability to read/navigate QNXT and Vitech systems; intermediate knowledge of Microsoft Word and Excel Strong knowledge of Coordination of Benefits (COB) and Medicare Secondary Payor regulations Effective oral/written communication; demonstrated ability lead/motivate others; work in a collaborative team environment