The Claims Research Analyst reviews and monitors adjudicated claims for file submission and upstream processing and communicates with provider agencies on claims submission, denial management, and system updates. This position serves to provide excellent customer service to provider agencies. This position facilitates training of providers and provides intermediate technical assistance. This position reviews auto-adjudicated claims and manually processes claims that pend for manual pricing or high impact criteria. This position analyzes available billing requirements, policies, procedures, and desk references to ensure proper protocol is practiced to accurately process claims. The CRA demonstrates and utilizes advanced analytical skills to process complex claims, analyze data, identify system issues, and utilize/build reports to enhance overall unit performance. This position aids in the leadership of the unit through facilitation of meetings, trainings, and process improvement efforts. The position requires the application of technical skills, communication across all departments including Utilization Management, Provider Networks, Finance (Purchasing, Accounts Payable, Accounting), Care Management). The position requires communication with external stakeholders including DHHS, DSS, DHB, provider agencies, third-party vendors, and other Managed Care Organizations. The position requires a high degree of professionalism and productivity.

This is a full-time hybrid opportunity. The selected candidate must report onsite to the home office (Morrisville, NC) for business and team meetings as needed.

Responsibilities & Duties

Process Claims

Review, key, process, status, track, and file Special Invoicing claims submissions which requires skill in managing and reconciling data between two information systems (finance/claims) Receive, review, analyze claims submitted via paper process to determine ability to process. If processable, key the claims accurately into the claims system Review and analyze received claims to determine accuracy of adjudication Identify adjudication errors, provider billing errors, and needs for technical assistance Monitor adjudication results using provided reports Apply basic claims knowledge in the review of patient and provider accounts to determine if account updates are needed Apply knowledge of eligibility, enrollment, prior approval, contracts, and credentialing to identify account needs Using existing reports, assure claims are processed within prompt payment guidelines Using Compliance Unit’s reversion packets, process refunds or adjustments Review claims for appropriate service event authorizations, consumer eligibility, and routine billing requirements Ensure appropriate coordination of benefits has occurred utilizing billing and payment policies and procedures Manually process claims unable to be adjudicated properly within MCS; including linking claims that error to the Exceptions Report Monitor and resolve technical issues within the Claims system Utilizing existing reports, monitor, track, and resolve Patient Monthly Liability corrections on provider claims and within NCTracks Review policy requirements associated with new or additional services to be processed and apply the knowledge to the processing of associated claims

Reporting

Utilize reports to identify and resolve claims errors or updates Create reports to monitor status of billing, including: paid and denied provider claims; unmanaged and managed service utilization, and consumer or payer-specific reports on claims reimbursement or adjudication

Communication 

Communicate and conduct liaison work across multiple departments to resolve claims denials/issues Communicate with high level external stakeholders like DHB, DHHS, and DSS  Communicate with internal stakeholders (all departments) Communicate with provider agencies Demonstrate professional and timely communication 

Provider Support

Provide training, education, and technical assistance to provider agencies related to basic claims submissions guidelines, denial management, MCS system use and updates, state/federal claims submissions regulations and updates Develop training materials to facilitate trainings

Assist with Claims Process Improvement

Identify resolution of system errors, review impact reports, communicate with providers and determine steps for reconciliation Provide information and feedback to the system team to support development of system enhancements in a structured manner aimed to eliminate system settings and or processes that contribute to poor results Maintain processes that are consistent with and compliant to CMS, state, federal and URAC standards, regulations and guidelines Read, review, analyze, and apply information from published clinical coverage policies and other NCDHHS documents to ensure the claims system and manual processes are incorporating required actions

Data Analytics

Demonstrate high level understanding of data; effectively utilize data mining tools; build report parameters

Leadership

Demonstrate leadership abilities through independent work, role modeling for peers, taking initiative with tasks and process improvement activities, engages in all aspects of claims actions Provide first level consultation to peers

Support Expansion and New Business

Learn new skills related to expansion and new business requirements per Alliance Health contracts. This includes: coverage of additional catchment areas, new covered services, processing and handling of physical health claims

Technical 

Apply claims processing skills. Apply detailed knowledge of how the Alliance Claims System (ACS) works. Identify ACS system issues, create tickets, strategize solutions with IT Development team, track tickets, communicate resolutions to providers. Analyze impact reports and follow resolution efforts through claims reconciliation

Minimum Requirements

Education & Experience

High School degree or equivalent and four (4) years of related experience (in customer service, claims processing, research/analytics, or communications); 

Or 

Bachelor’s degree from an accredited college or university in related field and two (2) years of experience (in customer service, claims processing, research/analytics, or communications). 

Preferred:

Experience with Medicaid and IPRS preferred. 

Knowledge, Skills, & Abilities

Knowledge of Microsoft Office, including Excel, Word, Outlook Working knowledge of healthcare services and systems Working knowledge of functions provided by Provider Networks, Utilization Management, Accounts Payable, Contracts, and Care Management  Knowledge of common claims denials and sources for correction Knowledge of Medicaid and IPRS rules  Knowledge of laws, legal codes, precedents, government regulations, and MCO policies and procedures Knowledge of medical terminology, CPT/HCPCS/UB04 revenue coding, modifiers, and billing regulations Excellent customer service skills Proficiency in written and oral communication sufficient for the sharing of technical information Strong organizational skills Ability to set objectives and prioritize workflow Ability to document clearly and accurately Ability to solicit cooperation from persons and departments throughout the organization Ability to adhere to department policies, procedures, and general practices Ability to work independently and as part of a team Ability to demonstrate professional conduct in all situations Ability to take initiative Ability to solve complex problems through the evaluation of alternative methods and solutions Ability to develop strong working relationships with divergent groups and communicate technical concepts to lay persons Ability to utilize efficient practices to complete assigned workload Ability to demonstrate professional presentation and conduct at all times Ability to independently follow instructions or desk procedures accurately and without error

Salary Range

$22.23 - $28.34/Hourly

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.  

 An excellent fringe benefit package accompanies the salary, which includes:    

Medical, Dental, Vision, Life, Long and Short-Term Disability Generous retirement savings plan Flexible work schedules including hybrid/remote options Paid time off including vacation, sick leave, holiday, management leave Dress flexibility