Responsible for conducting and assisting in documenting moderate to complex financial analysis projects following standard practices and procedures. Participates in studies to improve the operational and financial effectiveness of the unit. Extracts financial data from various accounting and information systems. Performs financial and cost accounting analysis of data. Description 30% Performs mo

Supports the Model Audit Rule (MAR/SOX) Department in the compliance effort that results in annual reporting to the Department of Insurance in activities such as, but not limited to risk assessments, process documentation (Financial, Operational and I/S Processes), identification of risks and key controls, testing of controls, reporting of deficiencies, evaluation of deficiencies, periodic reporti

Develops comprehensive reports and analyzes data in order to identify patterns and trends. Assists in creating materials that aid in illustrating analytical/data findings. Assists with sophisticated data interpretation, compilation, and verification to guide departmental efforts. Description 40% Designs, codes, maintain and executes simple to complex database programs for the extraction and pres

Responsible for the maintenance and processing of the request for medical records. Assists with department workflow to include opening/date stamping/routing of mail. Description 40% Handles departmental requests for medical records. Images medical records and other various documents. Indexes medical records (enters information into predefined fields on CRT or PC applications). 40% Sorts, prescre

Responsible for responding to routine correspondence and telephone inquiries pertaining to claims or appeals. Identifies incorrectly processed claims and completes adjustments and related reprocessing actions. Description 60% Researches and responds to telephone inquiries according to desk procedures, ensuring that contract standards and objectives for timeliness, productivity, and quality are m

Responsible for analysis, design, programming, and implementation of complex applications tasks and projects. Devise feasible, logical procedures to resolve business problems through the use of computer resources. Formulate scope and objectives through research to develop or modify complex systems. Review detailed specifications and recommend modifications. Design, code, test and debug complex app

Responsible for completing cost report reopenings within established timeframes and ensuring that the quality of our work meets CMS expectations. Reopenings include review of various provider types and issues related to the Medicare cost report. Description 40% Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities

Responsible for auditing group (small/large/complex) accounts to ensure premium payments and/or reimbursements are processed/reported in timely/accurate manner. Audits subscriber accounts to ensure premium payments are within grace period. Resolves billing/payment problems, adjudicates insufficient and/or incorrect payments back to subscribers. May serve as primary contact with group regarding mon

Responsible for auditing group (small/large/complex) accounts to ensure premium payments and/or reimbursements are processed/reported in timely/accurate manner. Audits subscriber accounts to ensure premium payments are within grace period. Resolves billing/payment problems, adjudicates insufficient and/or incorrect payments back to subscribers. May serve as primary contact with group regarding mon

Complete desk reviews for various healthcare providers. Maintain knowledge of CMS regulations and guidance, as well as knowledge and ability to use PC and applicable software to complete assignments. Ensure timeliness and quality expectations are met for all processes. Track progress of multiple workload assignments through completion to ensure timeliness and quality expectations are met. Descrip

Establishes and maintains positive relationships with network hospitals, physician and/or dental practices, and their representatives. Serves as point of contact for provider problems/issues. Responds to non routine or difficult problems/issues related to network contracts, reimbursement methodologies, benefit structure, medical policies, administrative policies, etc. Determines underlying cause(s

Responsible for moderately complex accounting activities relating to the maintenance of a complete and accurate general ledger and/or the resultant managerial reports and/or financial statements. Description 30% Reconciles assigned general ledger accounts of routine to moderate complexity. Initiates and/or processes journal entries into various accounts. Performs reviews of various systems activ

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement. Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings. Responsible for documenting cost savings related to reviews/audits. Identifies cha

Oversees the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities. Description 70% Manages the medical review process. Maintains a well trained staff. Develops/implements medical review strategy wit

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members. Description 70% Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system a