Claims Coordinator (Hybrid - Troy, MI) - Health Alliance Plan
🔍 Troy, Michigan
General Summary:
Utilize claims adjudication and investigative experience to support claim administration functions and handling of priority provider focused claim projects. Collaborate with department leaders and staff on claim adjustment and recovery initiatives including system-automated processes. Develop and implement new internal procedures and new system release testing initiatives.
Principal Duties and Responsibilities:
- Execute submitted Mass Claim Adjustment Request Forms (MCARF) requests and analyze the best means to execute the approved request, including; execute the Facets mass claim adjustment jobs and manage the fallout of claims to ensure proper resolution, and coordinate execution of external programs to copy reload claims through 837 files. Update the MCARF with the claim outcomes for each executed job through inventory tracking repository
to inform internal customers who submitted the requests. - Resolves claims, conducts formal account reviews, identifies lost charge recovery, analyzes and documents delays and payment variances.
- Analyze Provider Claim data to reconcile accounts submitted by hospitals or physicians through a data reconciliation program. Provide results to requestor. Assist in formulating plans to develop an ongoing process to identify opportunities for recovering erroneous or fraudulent claims.
- Analyze various payment issues and make recommendations to the appropriate departments including Finance and IT for improvements. Work with providers to collect monies due to HAP in cases of overpayments. Makes collection contacts to delinquent accounts and performs any tasks or duties in
order to aid in collection of past due or overdrawn accounts. - Acts as a project team lead, specifically on developing and defining requirements and testing activities. Participate in User Acceptance Testing (UAT) and system testing for computer application releases, make recommendations as needed.
- Conduct Division Performance Monitoring and analyze claims data to design and evaluate quality measurements and improvement programs. Monitor the progress of these improvements. This includes the automated release programs, unposted workgroups and results of corporate audit recommendations.
- Provide guidance, assistance, coordination and follow-up on complex problems by investigating all options and ensures resolution.
- Investigate, evaluate, and create documentation of Claims Department policies, procedures and job aids.
- Assist with medical and hospital claim entry and high dollar claim review.
- Other duties as assigned.
Education/Experience Required:
- Associates Degree
- Related and relevant experience may be considered in lieu of academic requirements. Related experience is defined as four (4) years’ experience in claims adjudication, claim inquiry resolution, and/or claim adjustment experience.
- Three (3) years’ experience adjudicating claims.
- One (1) year experience processing claims including claim adjustments.
- Two (2) years’ experience investigating and processing claim inquiries.
- One (1) year experience processing claim adjustments.
- Minimum three (3) years of claim financial audit experience.
- Minimum five (5) years’ experience working in the health care industry.
- Knowledge of CPT, HCPCS, and ICD-10 coding systems and working knowledge of healthcare compliance are required.
- Strong MS Office skills including Advanced Excel - ability to create your own spread sheets and manipulate information as needed.
Preferred:
- One (1) year experience processing Pega cases.
- One (1) year experience processing Facets claims and adjustments.
- Experience with Cognos query and reporting.
- Experience with Power BI reporting.
- Experience using MS Office 365, including Outlook and TEAMs.
- Database management.
- Minimum one (1) year Customer Service Call Center experience.
Skills and Abilities:
- Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related projects.
- Demonstrated ability to collect and prepare data for written/oral presentations.
- Demonstrated ability to communicate effectively.
- Ability to interact with outside sources and maintain professional contacts.
- Excellent written and verbal communication skills are essential.
- Must be able to work effectively with persons of varying position levels and diverse interests.
- Understanding of healthcare industry and managed care concepts.
- Knowledge of a table driven claims processing system.
- Knowledge of Windows, Microsoft Excel and Word, Query Tools (COGNOS, etc.), Power BI and Implementation/Administration of Packaged Claims Processing Applications.
- A high level of human relations skills.
- Ability to adapt to a constantly changing environment.
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, Â Â Â Â Â companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
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Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s Â
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Â Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. Â My Choice Rewards is a program as diverse as the people it serves. Â There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. Â As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.