Analyst Healthcare Claims Customer Service (Remote)

The Claims Customer Service Analyst is accountable for and oversees the following tasks:

• Manage all claims appeals, including disputes, redeterminations, and reconsiderations
• Confirm reimbursement accuracy and work with Networks, Medicaid, and Medicare in any questions/concerns
• Analyze claims activity and work reports received by Providers, Networks or Management
• Perform claims reprocessing, reexporting and address medical billing issues
• Assist with special reports of tracking problems with medical claims according to HIPPA guidelines, contracts, fee schedules and provide education to providers/internal staff as applicable
• Apply knowledge of coding to determine if dispute is valid
• Review documentation, analyze reject claim data, justify CPT & HCPCS codes and pay HCFA-1500 and UB92 claims.
• Take inbound customer-service calls and make outbound calls to providers
• Investigate pending claims and resolve discrepancies
• Explains EDI claims transmissions and educates providers on rejection reasons and how to resolve the issue to ensure clean claim submissions
• Contacts providers to provide necessary billing guidelines to comply with quality and process standards
• Follows established guidelines specific to each claim report or inquiry
• Review, coordinate and respond to all request or record requests in a timely order
• Responsible for delivery of EOP’s to providers after each claim run
• Responsible for investigating clearinghouse rejections, ensuring rejection letters are accurate and of high quality
• Responsible for collaborating with Networks on escalating all high-volume rejection/denial claims by provider as communicated in Bi-weekly Claim Dashboards and providing an improvement plan on submission of clean claims for timely payments
• Take part in the monthly Claim Webinar Training to our Network

Essential Job Functions And Duties

• Oversees review of claims inventory for quality and findings in external audits from all Payors/Providers as well as annual internal audit in accordance with tango Claims Policies and Procedures
• Handling of all claim escalations (verbal and electronic) in accordance with tango Claims Policies and Procedures
• Escalating all high-volume Provider Claim issues to ensure positive rapport with our network Providers in accordance with tango Claims Policies and Procedures
• Mentoring new team members and providing assistance and review of quality of work during onboarding
• Perform other duties as assigned within the scope of responsibilities and requirements of the job
• Performs the essential functions of this job with or without reasonable accommodation

Essential Qualifications

Years of Experience and Knowledge

• 5 to 7 years of direct experience minimum in Claims Adjudication and Clearinghouse submissions/rejections (required)
• Advanced level of skills and knowledge of technical system operations (required)
• Detailed knowledge of medical coding; HIPPS, CPT and HCPCS codes
• Solid understanding of enrollment and eligibility as well as claims paying for all lines of business
• Solid understanding of claim data sets required on Encounter Files to ensure resubmission of claims/disputes are in accordance to 837 CMS regulations
• 1-3 years working in a claims inbound call center (required)
• Professional level training that provides a general understanding of:

• Administration of all contractual obligations
• Audit and billing procedures
• Policies and procedures
• Processing of accounts receivable and eligibility requirements impacts claims processing
• Vendor data feeds and discrepancy process
• Administrative and regulatory requirements
• Technical workflow processes
• Functional requirements of the system
• Solution design documents.

• Billing and delinquency procedures
• Accounts receivable process
• System testing and enhancement process
• Web portal data support

Skills And Abilities

• Advanced level Microsoft Office skills (PowerPoint, Word, Outlook)
• Advanced level Microsoft Excel skills
• Advanced level of Web Reports and how to read 837 files to support working of encounter rejections
• Interpersonal, communication (written and verbal) and presentation skills
• Analytical, research, problem solving, and decision-making skills
• Ability to monitor team goals
• Ability to lead and coach team members

Job Type

• Full-time

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.