Claims Examiner - Xcelys Remote, Temporary

NTT DATA Services•Chino, CA

13d•Remote

About The Position

NTT DATA is seeking a Claims Examiner - Xcelys Remote, Temporary to join their team. This role involves reviewing written dispute requests from providers regarding denied or incorrect payments based on contractual arrangements. The Claims Examiner will interpret provider and health plan contracts to ensure accurate claim payments or denials, adjust claims as needed (including calculating interest and penalties), and identify potential issues affecting claims processing. They will communicate with providers in writing, manage workload efficiently, and ensure compliance with departmental guidelines. The role also includes documenting disputes, maintaining quality and quantity standards, and updating the Provider Dispute Database. The Claims Examiner will keep their Team Supervisor informed of potential problems and advise management of issues impacting claim processing or system configuration. The position is temporary and remote.

Requirements

Ability to interpret provider and health plan contracts.
Knowledge of RBRVS and Medicare guidelines.
Ability to identify potential issues related to system configuration, benefits, eligibility, authorizations.
Ability to communicate to Provider in writing.
Ability to document each dispute accurately in Provider Dispute Database.
Maintain minimum standards set for the department for quality and quantity of appeals received.
Ability to keep Team Supervisor aware of potential problem issues.
Ability to advise management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.

Nice To Haves

Experience with Xcelys

Responsibilities

Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers, regarding either Professional or Institutional Claims.
Interprets provider and health plan contracts to ensure accurate payment of claims or denial of services based on the terms of the provider contract and the financial responsibility as set in the health plan contract, including RBRVS and Medicare guidelines as it applies to contracted and non-contracted providers.
Adjusts claims, as appropriate, including calculation of interest and penalties due when applicable.
Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc., affecting the Claims Departments ability to process claims accurately and forwards those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments.
Plans and organizes workload to ensure efficient and compliance resolution of issues.
Communicates to Provider in writing, for all disputes utilizing system formatted letters in a clear and concise manner in accordance with all guidelines set by the department.
Responsible for requesting special check run requests to insure compliance.
Monitors warning reports daily to insure compliance.
Completes provider education calls based on outcomes of PDR.
Responsible for documenting each dispute in Provider Dispute Database accurately for reporting purposes for management reports to all customers internally and externally as required by AB1455.
Maintains minimum standards set for the department for quality and quantity of appeals received.
Updates Provider Dispute Database with the outcome resolution of issues as appeals are completed.
Responsible for keeping Team Supervisor aware of potential problem issues for education to all departments involved with claim issues.
Advises management of issues identified which have an impact on accurate processing or system configuration of claims per contracts or guidelines for non-contracted providers.
Performs any other assigned duties and delegated by the Management.