Medical Review Claims Analyst II

CoventBridge Integrity Systems; United States; Remote; USD 50,000 - 55,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

LTD/STD

401(k) with match

PTO & holidays

Tuition assistance

Job summary

CoventBridge Integrity Systems is seeking a Claims Analyst II for remote work in the United States. You will review Medicare and Medicaid claims, re-price overpayments, and assist with medical review during fraud investigations. Strong knowledge of medical terminology and coding principles is essential.

The role reports to the Medical Review Project Manager and can be performed remotely from home. You will work with MACs to move claims as needed, maintain data in Excel, and support reporting

Qualifications

• Must have extensive knowledge of medical terminology and Medicare/Medicaid claims processing.
• Knowledge of Medicare/Medicaid guidelines and coverage is required.
• Excellent verbal and written communication skills; ability to work independently.

Responsibilities

• Maintain workflow balance to ensure re-pricing requests are completed within time limits.
• Utilize medical terminology and coding principles in re-pricing claims.
• Complete assignments meeting quality assurance goals for accuracy.
• Prepare monthly pre-pay saving reports and track pre-pay edits.
• Attend required trainings and protect PHI/HIPAA confidentiality.

Skills

Medical terminology

Medicare/Medicaid knowledge

Claims processing

MS Office

Communication skills

Independent work

Education

High School Diploma or GED

CPC Certification preferred

Tools

MS Office

VMS

Job description

Claims Analyst II - REMOTE

The Claims Analyst II position is responsible for organization and entry level review of Medicare and Medicaid claims. Responsible for re-pricing and calculation of overpayments for completed Medical Review post pay case reviews, and any re-pricing needed for those reviews that go through the appeal process. Provides support to Medical Review during the course of fraud investigations or other program integrity initiatives, such as requests for information needed to complete Medical Review. Applies a working knowledge of medical terminology and coding principles in the re-pricing of Medicare and Medicaid claims. Responsible for pre-pay communication with each MAC on a daily basis should claims need moved to specific locations. Also performs such duties as keying information into databases, scanning and assisting with reporting functions.

Overview

The Claims Analyst II position is responsible for organization and entry level review of Medicare and Medicaid claims. Responsible for re-pricing and calculation of overpayments for completed Medical Review post pay case reviews, and any re-pricing needed for those reviews that go through the appeal process. Provides support to Medical Review during the course of fraud investigations or other program integrity initiatives, such as requests for information needed to complete Medical Review. Applies a working knowledge of medical terminology and coding principles in the re-pricing of Medicare and Medicaid claims. Responsible for pre-pay communication with each MAC on a daily basis should claims need moved to specific locations. Also performs such duties as keying information into databases, scanning and assisting with reporting functions.

In assuming this position, you will be a critical contributor to meeting CoventBridge Integrity System's objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.

The Claims Analyst II will report directly to the Medical Review Project Manager and will work in our Grove City, OH office. If not local, remotely from a home office.

Responsibilities/ Requirements

Responsibilities:

• Maintain workflow balance to ensure re-pricing requests are accurately completed within the department’s time limit established for this work
• Utilize a working knowledge of medical terminology and coding principles in re-pricing claims
• Complete assignments that meet or exceed the quality assurance goal for accuracy
• Implement, terminate, and track pre-pay edit requests daily
• Prepare monthly pre-pay saving report(s) in a timely manner
• Facilitate movement of claims to the UPIC ‘safe locations’ when medical records are received for pre-pay claims
• Adjudicate DME pre-pay claim decisions in VMS
• Facilitate daily adjudication of pre-pay claims based on MR review decisions
• Scan, review, and file Medical Review records and other documents as needed
• Key information into Excel spreadsheets as needed
• Attend departmental and required education and training programs
• Follow all confidentiality and security guidelines regarding PHI and HIPAA protected information
• Perform other duties as assigned by Management that contribute to UPIC goals and objectives, and comply with the Program Integrity Manual, Statement of Work guidelines and CMS directives and regulations

Requirements:

• Extensive knowledge of medical terminology and coding principles
• Knowledge of Medicare and Medicaid guidelines and coverage is required
• Ability to read Medicare and Medicaid claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required
• Working knowledge of Medicare and Medicaid Claims pricing and payment systems
• Excellent verbal and written communication skills
• Ability to work independently with minimal supervision
• Ability to work in MS Office environment

Educational Qualifications:

• High School Diploma or G.E.D equivalent
• Certified Professional Coder (CPC) preferred
• Extensive knowledge of medical terminology and experience in the analysis and processing of Medicare and Medicaid claims is required, as well as experience related to the specific workload of the individual task order which may be further defined in the Task Order Statement of Work
• One year or more experience in medical terminology and Medicare claims payment systems or has attained CPC certification
• Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act

Benefits

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service

The salary range for this role is $50,000 to $55,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be b ased on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

At this time, CoventBridge is not considering candidates who require visa sponsorship, currently or in the future, including but not limited to H-1B, H-2B, E-3, TN, O-1, F-1 (OPT/CPT, or J-1 Visa Statuses.)

About Us:

CoventBridge Integrity Systems delivers investigative services, technology, and expertise that help healthcare and government organizations protect critical programs, strengthen oversight, and address fraud, waste, abuse, and operational risk.

CoventBridge Integrity Systems is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics and maintains a drug-free workplace.

CoventBridge Integrity Systems is committed to the full inclusion of all qualified individuals. As part of this commitment, CoventBridge Integrity Systems will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; [e-mail].