Sr Claims Reviewer

Sr Claims Reviewer at TriWest Healthcare Alliance Sr Claims Reviewer at TriWest Healthcare Alliance in Charleston, South Carolina Posted in 16 days ago.

Type:

Full-Time Job Description:

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary Provides Subject Matter Expert (SME) support to Claims Administration functional teams, by serving in a team lead role. Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services, as it relates to their assigned function (s). Applies clinical, coding, and processing knowledge to effectively perform assigned responsibilities. This role will serve as a SME and will collaborate with Claims leadership, Training, the Claims Content Specialist, and internal business partners to ensure procedures and training materials are accurate and complete. The Sr. Claims Reviewer will act as a Team Lead to Claims Reviewers by answering questions, performing on-the-job (OTJ) training, as needed. This position will also support the Supervisor, Claims Admin with daily inventory management workflows and the assignment of work to claims reviewers.

Education & Experience Required:

• High School Diploma or GED
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background
• investigation
• 3 years claims review experience
• Knowledgeable in medical, institutional, and behavioral health claims processes
• Demonstrated ability to communicate effectively, both verbally and in writing
• Intermediate proficiency in

MS Office Suite Preferred:

• Associated degree or higher in related field
• Government claims experience
• Claims coding certification or equivalent experience
• Previous experience in a Team Lead or higher role Key Responsibilities
• Assists in the development of claims policies, procedures, training materials, and communications.
• Serves as a Claims SME and collaborates in cross-functional forums, as assigned.
• Conducts training and quality improvement activities within assigned functional team.
• Effectively performs delegated tasks pertaining to daily inventory management workflows and routing of work.
• Acts as a point of contact for claims-related inquiries and escalations, in the Claims Supervisor's absence.
• Validates claim outcomes for accuracy and routes for adjustment, as necessary.
• Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.
• Adheres to all desktop procedures for assigned function.
• Identifies and appropriately communicates processing discrepancies or trends.
• Reviews claim data for process improvements.
• Communicates effectively and professionally with internal and external partners.
• Consistently meets or exceeds individual performance expectations.
• Identifies and reports potential quality or fraud issues per established procedures.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies Coaching / Training /

Mentoring:

Actively foster actions required for desired business outcomes through ongoing constructive feedback. Commitment to

Task:

Ability to conform to established policies and procedures; exhibit high motivation. Communication /

People Skills:

Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy:

Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Coping /

Flexibility:

Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

High Intensity Environment:

Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Organizational Skills:

Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Team-Building /

Team Player:

Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills:

Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract. Working knowledge of behavioral health claims adjudication principles.

Working Conditions Working Conditions:

• Favorable working conditions in a climate-controlled office space
• Must be available to cover any work shift
• Works within an office environment with minimal travel required
• Extensive computer work with prolonged sitting TriWest job postings typically include a salary range, which can vary based on the specific role and location , but generally this position ranges from around $59,000 to $66,000 per year.

Company Overview Taking Care of Our Nation's Heroes. It's Who We Are. It's What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®! Our job is to make sure that America's heroes get connected to health care in the community. At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996. Benefits We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes: Medical, Dental and Vision Coverage Paid time off 401(k) Retirement Savings Plan (with matching) Short-term and long-term disability, basic life, and accidental death and dismemberment insurance Tuition reimbursement Paid volunteer time Equal Employment Opportunity TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.