Claims Adjustment Analyst - Out of Network Dispute Coordinator

Baylor Scott & White Health•Dallas, TX

17h•Hybrid

About The Position

The Claims Adjustment Analyst performs extensive reviews on member or provider claim issues to calculate root cause research. Researches and investigates previously paid or denied claims to correctly apply benefit determination and pricing in accordance with claims processing guidelines. Hybrid position, will be onsite twice per week. Must live in Baylor Scott & White service area- DFW, Central Texas (Temple/Waco), Greater Austin Area, or College Station.

Requirements

EDUCATION - H.S. Diploma/GED Equivalent
EXPERIENCE - 3 Years of Experience

Nice To Haves

HMO/PPO experience is preferred.
Previous Claims experience required.
Medical terminology, CPT, HCPCS, ICD9, ICD10, and coding preferred.
Ability to use good judgment and logic in evaluating and resolving difficult claims issues.
Ability to work independently, with minimal supervision to meet internal and external customer satisfaction goals. Must be a sound decision maker.
Responds positively to goal-setting and performance measurement. Easily adapts and responds effectively to shifts in priorities and unexpected events.
Excellent verbal and written communication skills with attention to detail.
Ability to comprehend and adhere to policies and procedures
Excellent analytical, problem solving skills and organizational skills.
May be required to work in excess of regular scheduled hours.

Responsibilities

Performs extensive reviews on Out of Network claim issues to determine root cause analysis. Documents, tracks, resolves and reports findings. Provides expert assistance to other staff by researching and resolving payment issues resulting from Out on Network claim disputes which can include the Texas Department of Insurance Independent Dispute Resolution and the No Surprises Act.
Participates in assessing written responses to payer settlement offers that result in an adjustment to previously processed claims. Provides an enhanced level of claims knowledge and assistance to the Managed Care and Revenue Cycle teams. Handles escalated caller issues from the Customer Service team. Properly responds to and follows up on any outstanding issues.
Researches and submits written inquiries, mediator forms and invoices and emails regarding Out of Network claims effectively gathering documentation needed to settle or eventually mediate. Examines information including, but not limited to, authorizations, payments.
Interprets and processes payments in accordance with system guidelines. Identifies underpayments, records and sends letters requesting payment.
Works adjustment inventory from assigned queues and service forms to ensure all claims are processed within established turnaround time as directed by department policies and procedures. Consistently meets/exceeds productivity standards and accuracy standards for payment, procedural and financial.
Handles individual payer issues through phone calls, service forms or correspondence for final resolution. Obtains information and responds to questions regarding third party liability, and acts in accordance with established policies and procedures. Accurately documents phone log records for each payer, mediator and arbitrator inquiry. Enters appropriate remarks or forwards requests to appropriate area as necessary
Completes reports and special projects to ensure prompt adjustment or recovery of underpaid claims in accordance with turnaround time standards. Updates service excellence spreadsheet for tracking, trending and reporting. Identifies and reviews problems, systematic or procedural, with management. Performs follow-up and takes all necessary actions required to resolve errors and findings.
Protects data integrity and validity. Abides by patient confidentially (HIPAA) regulations and guidelines for accessing and disclosure of protected health information.