Insurance Integrity Specialist at Marjon Management Advisors, LLC Insurance Integrity Specialist at Marjon Management Advisors, LLC in Melrose, Massachusetts Posted in 1 day ago.

Type:

full-time We have an immediate need for an insurance processing professional for our growing healthcare client. This is a temp role on-site in Beverly and the hours are 8:00am-4:00pm. The Insurance Integrity Specialist plays a vital role in safeguarding the financial sustainability by overseeing all aspects of the Medicaid (MassHealth) eligibility process. This position ensures participants maintain the coverage required to receive comprehensive care, preventing loss of reimbursement through accurate documentation, third-party liability investigations (including Medicare Coordination of Benefits), and proactive collaboration with families and clinical teams.

Responsibilities Medicaid & MassHealth Lifecycle Management Application Oversight:

Manage the timely completion of initial Medicaid applications and annual redeterminations for all new and existing participants.

Enrollment Collaboration:

Partner with Enrollment staff to secure Medicaid eligibility, a key requirement for most participants entering the program.

Eligibility Maintenance:

Work closely with Social Work teams, participants, and families to ensure continued eligibility without interruption.

Compliance Guidance:

Provide education and guidance to internal staff and external stakeholders on Medicaid rules and regulatory requirements to maintain program compliance.

Coordination of Benefits & Third-Party Liability Medicare Review & Documentation:

Investigate and document Medicare Coordination of Benefits to determine primary and secondary payer responsibilities.

Insurance Monitoring:

Track and manage claims related to Workers' Compensation, No-Fault insurance, and other third-party coverage to prevent improper Medicare or Medicaid payments.

Reporting & Updates:

Report additional insurance coverage to the Medicare contractor and update internal systems accordingly.

Data Integrity & Financial Resolution Database Oversight:

Maintain accurate participant records, including SSI/SSP status, Patient Paid Amounts (PPA), and projected review dates.

Discrepancy Resolution:

Collaborate with the Fiscal department to promptly resolve Medicaid payment discrepancies and minimize financial risk.

Payment Verification:

Audit payment data to ensure alignment with applicable state and federal reimbursement schedules. Qualifications Knowledge of Medicaid/MassHealth eligibility requirements preferred, though not required. Ability to work independently and exercise sound judgment. Comfortable operating in a fast-paced environment. Willingness to travel within the service area and meet participants in their homes as needed. Strong communication, leadership, and problem-solving skills. Salary $25-$27 per hour