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Adjustment Project Data Coordinator - Claims Adjustments

Maumee, Ohio
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Description

At Paramount, we offer insurance to both large and small groups and also cater to Medicare (Paramount Elite) subscribers in northwest Ohio and southeast Michigan. Our Medicaid product (Paramount Advantage) services those living in the state of Ohio. We maintain an accreditation by the NCQA – the National Committee for Quality Assurance – for our Ohio HMO, Elite and Advantage products. We’re also part of ProMedica, which is ranked the second most integrated health system in the U.S. and No. 1 in the Midwest. For more information about Paramount, please visit our website http://www.paramounthealthcare.com.

 

Basic Purpose

Responsible for the reconciliation of outsourced payment programs, CMS debt collection process and counter accumulation processes. Coordination and analysis of data, the tracking of reversals and debits of claims, adjusting claims and documenting each transaction as outline in the contracts to ensure compliance within the respective agreement and accurate payments are reflected in claims processing system.  Processes claim adjustments in claim processing system as well as using the batch adjustment process on projects as needed.  Maintains the special project log.  Assists daily in accumulation of production numbers.  Success in this position is based on the individual's ability to effectively prioritize own work, identify and resolve complex issues in a professional manner, as well as work in a team environment to achieve a common goal. Support internal customers with prompt turnaround on inquiries. 

 

Primary Duties

  • Daily and weekly compile the teams’ Production reports and distribute to the appropriate staff.  
  • Responsible for working and maintain CLMX165 and output reports clmu156, bcprpt1 and bcprpt2   Accumulator report prior to claims payables each week to ensure prompt pay compliance and to eliminate any beneficiary impact by the incorrect member liability accumulators.
  • Responsible for working and maintaining Cpp10000/cpperr- This report is required to be reviewed and worked within 5 days of receiving to meet compliance prompt pay standards.  Must resolve issues keeping the claims from hitting claims payable. 
  • Work as directed on hot priority items or special projects to provide expedited resolution (to include, but not limited to, fee schedule adjustments and provider entry errors). Must know how/where information can be located to resolve complex claims inquiries (e.g. internet sites, UB Editor etc.).   
  • Promptly adjust or adjudicate claims to meet established Plan standards.
  • Pended claims - no more than 2% over 30 days    
  • Accurately process claims and adjustments, and apply appropriate processing procedures to ensure established accuracy thresholds are met.
    • Payment 98%
    • Procedural 98%
    • Financial 98.5%
  • Maintain Plan standards in response to requests from internal customers.
  • Work units’ primary resource for testing system upgrades, conversions, product line specific changes etc.  Mentor the adjustment adjudicators and perform quality assurance reviews as directed. This includes the QA process of the Refund remark report before sending to Supervisor.
  • Actively participates in shared accountability and commitment for departmental and organizational-wide results.  Supports departmental and team goals and objectives. 
  • Must attend all required claims training or refresher classes.
  • Perform other duties as directed to support overall claims operations.
  • Responsible for monthly reconciliation of claim invoices related to credit balance, post payments OON re-pricing contracts and PPO networks. Requires promptness in the review and reconciliation to be within 10 days of receipt.  
  • Responsible for Medicare Debt Collection requests we receive from CMS and/or directly from a group in a timely manner.  This includes investigation, validation and verbal and written correspondence. All must be timely to avoid interest payments. 

  • High School diploma or GED
  • Five years or more in claims and/or adjustment processing experience preferred
  • Demonstrated proficiency in Word and Excel required; Access preferred
  • Detailed knowledge of benefit and pricing mapping is strongly preferred
  • Detailed knowledge of governmental regulations, as well as Ohio and Michigan Prompt Pay compliance
  • Detailed knowledge of UB and HCFA claim formats, electronic claim submissions, coordination of benefits, and group-specific performance guarantees.
  • Knowledge of provider billing and coding practices.
  • Demonstrated knowledge of imaging systems preferred.
  • Excellent written, verbal, and interpersonal communications skills required.
  • Ability to work independently and ability to plan/organize multiple tasks.
  • Ability to work in a production environment that can be stressful.
  • Maintain a high level of motivation, initiative, and accountability. Maintain confidentiality.
  • Handle conflict in a productive manner.
  • Must pass a written skills test at 80%
     

 

ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio.  For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace

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