Position Summary

The Claims and Eligibility Specialist reports to the Human Services Program Development Supervisor within the Client Refugee Resettlement Program (RRP) and is responsible for the manual transfer of data from hard copy format to computer files or database systems to process medical and dental claims submitted by health care providers for specific health coverage for refugees, Refugee Medical Assistance (RMA), claims per client policies and procedures. Responsibilities also include processing payments to providers using CMS-1500, ADA Dental, and UB-04 claim forms in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines; processing medical prior-authorization and dental pre-treatment estimate requests for review by medical and dental consultants; making RMA benefit eligibility determinations; working directly with primary and preventive health services providers and contracted medical and dental consultants; educating providers about RMA, RRP services and benefits, and relevant governing federal laws and regulations; requesting medical documentation from providers; obtaining consent forms; reviewing the history for duplicates or duplicate payments and ensuring that the system appropriately processes claims; identifying third-party liability and ensuring that needed documentation accompanies submissions; processing prior authorization; requesting supplements and linking documentation; and recouping and voiding claims. The Claims and Eligibility Specialist is also responsible for multiple projects relating to claims processing and adjudication and using WellSky to generate remittance-payment voucher-claims packets for submission to Accounts Payable after approval by the Authorized Approver.

The Claims and Eligibility Specialist will also perform statewide records research in systems and convert hard copy documents into digital copies using scanning equipment. Duties typically include managing and storing files on a computer, raising concerns and issues about scanning equipment with technicians, and inspecting output quality. Daily task assignments are based on immediate business needs.

Under direction, the Claims and Eligibility Specialist performs administrative work of considerable difficulty including research, eligibility determination, operations planning and report preparation, developing or

modifying procedures and forms to improve program effectiveness, coordinating RRP administrative matters, composing correspondence concerning a wide variety of issues; coordinating activities with other departments and entities and community organizations. Participates in the development and implementation of policies, procedures, and systems.

1. Processes and adjudicates medical, dental, and vision claims and prior authorization/ pre-treatment estimate requests, researches complex medical claims, determines eligibility for services and medical/dental/vision benefits, and communicates with healthcare providers regarding credentialing, claims, billing, or eligibility issues. 65%
2. Generates RRP reports as required. Develops or modifies procedures and forms to improve program effectiveness and efficiency. 15%
3. Maintains client files, both paper and electronic, in accordance with client confidentiality and HIPAA guidelines. 10%
5. Participates in efforts to research and pursue funding and other resource opportunities that will contribute to successful refugee resettlement and integration efforts. 5%
6. Performs other administrative support tasks for RMA, such as gathering and maintaining data and other information necessary for programmatic assessment, analysis, and reporting. 5%

Major duties and responsibilities include, but are not limited to:
Accurately and manually enters a high volume of data from multiple sources in a database, ensuring that all necessary data is entered as submitted by health providers.
Enters and transcribes from hard copy formats to medical claims computer files, form types CMS 1500s, UB04s, and ADA Dental Forms, while meeting established quality and production standards.
Processes pending (adjudicated) claims, including requesting medical documentation from health providers; obtaining consent forms, explanation of benefits (EOB), and third-party liability; reviews the history for duplicates or duplicate payments, identifies inappropriate billing patterns and forwards to appropriate unit, ensures medical documentation is included with submissions, supplements and links documentation, and recoups and voids claims.
Ensures that the system is appropriately processing claims, identifies problems/issues and notifies appropriate parties for resolution, identifies inappropriate billing patterns that are reported to the Audit Unit or to the client's Fraud Unit for review. Verifies eligibility of claims using the client's policies and procedures and coordinates claims with third-party liability. Reprocesses Prior Authorization Claims.
Reviews and links scanned supplemental documents to the appropriate claim using client systems. Re-routes unprocessed mail to the appropriate destination and writes, types, or enters information on a computer via Google Suite or other departmental systems, using a keyboard, to prepare documents or reports.
Duties also include pulling claim images, verifying attached documentation for Medicare EOBs and third-party liability, and verifying key fields on the claim.
Lifts, opens, sorts, batches by claim type into predetermined batch sizes, and prepares various forms for scanning - removing staples, paper clips, etc., and repairing documents as needed.
Scans documents, transcribing from hard copy formats to computer files. Verifies data to ensure accuracy while appropriately formatting and making adjustments for paper size/weight, ink color, paper color, etc., to ensure acceptable image quality and maintain an even workflow. Responsible for logging automatically assigned document numbers during scanning for future retrieval and archiving in the RMA Google system.
Files scanned original document images pursuant to established guidelines to ensure accurate filing and to facilitate timely retrieval of information. Ensures quality control by reviewing rejected scanned documents to identify/rescan poor quality document images, ensuring that all images entered in the system meet established quality standards, and resolves inconsistencies.

Knowledge, Skills & Abilities (KSAs):

Knowledge:
Auditing and analysis procedures to determine compliance with the client HCCCS/RMA requirements
Medical terminology, CPT codes, ICD-9 codes, HCPCS codes, and CDT codes
Applicable third-party liability laws for State and Federal programs; principles of medical pricing (i.e., DME equipment, drugs, multiple surgical procedures)
Entering Medical/Dental/Vision documents into the claims processing system
Document sorting, batching, routing, and coding practices/procedures/guidelines
Thorough knowledge of all aspects of claims processing

Skills:
Computer skills: operating a keyboard, ten-key calculator
Accuracy and speed
Intermediate computer skills
Oral and written communication
Interpret rules and regulations, policies and procedures
Analyze reports
Professional interpersonal relationships
Analyze problems and develop action plans for correction
Quality assurance skills to ensure effectiveness of final product
Microsoft Windows (Excel and Word), Google, WellSky (claims processing), or comparable software

Abilities:
Determine a pattern of inappropriate billing, which may indicate fraud
Analyze system issues, elevating concerns to management
Know when to report problems/issues in adjudication and when to proceed on their own
Provide technical training as required
Work in a fast-paced environment independently and as a team
Communicate effectively verbally and in writing
Speed and accuracy to meet performance measurements
Learn and closely follow established policies, procedures, and guidelines
Prioritize projects and be able to change priorities based on the team's needs

The KSAs needed to be successful in this position are acquired through a combination of education, training, and work experience, such as a minimum of three (3) years of direct experience processing medical, dental, and hospital claims and a minimum of three (3) years of computer experience including Windows, Access, Excel, Google Workspace, and related software. An equivalent combination of education and experience sufficient to perform the duties may be substituted for the above.

Selective Preference(s):
Minimum one year of experience in health coverage/health insurance processing. Demonstrated ability to create process flows and documentation on work processes.

Preferred:
Experience adjudicating claims and working knowledge of medical coding. Proficient in Google, WellSky, and Microsoft Office.

Should the position require driving or the use of a vehicle as an essential function of the job to conduct client business, then the following requirements apply: Driver’s License Requirements.

Notes:
Onsite
8:00 AM - 5:00 PM