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Identifies, researches & validates cases involving Medicare, Other Commercial Carrier, Dual Coverage & other 3rd Party Liability situations, including researching primacy determination on complex cases involving another payor, claims cost avoidance.
• Distributes eligibility surveys to appropriate members for the entire membership database.
• Places primary calls to members for the entire membership database when surveys aren't returned.
• Applies National Association of Insurance Commission(NAIC) guidelines to determine primary/secondary liabilities when required.
• Applies Medicare Secondary Payor & NAIC rules & regulations to determine Medicare & Commercial Primacy determination for accurate payment of benefits relative to Claims adjudication & billing.
• Generates & analyzes applicable departmental reports, documents revenue recovery opportunities from providers, attorneys & other insurance adjusters, etc. & communicates to Claims Administration.
• Reviews & responds to various forms of inquiries from CMS, providers, members, attorneys & other insurance personnel.
• Manages Macess workflow queues according to Claims department policies, guidelines & turn around time.
• Assists in the development & implementation of policies & procedures for the department & COB unit. Recommend changes to management.
• Interprets new laws & regulations in all operating jurisdictions including CMS, NAIC & federal & state. Communicates changes in regulations appropriately to all interested parties. Advise management of pending changes.
• Maintains working expertise of:
• Covered & non-covered Medicare benefits administration & Health Plan benefits.
• Specific provider contractual arrangements.
• Provider Service Center processes & procedures.
• Appeals process.
• Changes in Claims processing policies & procedures.
• Acts in the capacity of Medicare & Commercial COB subject matter specialist to several internal departments & external customers/clients.
• Provides linkages between the departments to facilitate recovery, billing & other primacy related issues.
• Maintains monthly reports on liens, 3rd Party & Workers Compensation questionnaires, recoupment revenue, adjustments & other related activities.
• Performs retroactive claims payment audit for newly identified Medicare & Commercial primary members. Communicates recovery opportunities to Claims Administration.
• Maintains Medicare & Commercial primacy determinations in TPL module, HSD Diamond & PFS Billing system.
• Performs other duties as directed.
• 4yrs of background specializing in COB, Medicare, Medicaid, Dual Coverage TPL &/or Workers Compensation claims.
• Demonstrated skill in health insurance claims processing & benefits environment. Working knowledge of Medicare, medical & other insurance terminology.
• Background w/ computer applications & other PC based skills.
• Bachelor's degree or the equivalent relevant years of relevant work background required.
• Demonstrated background in industry practices & regulations in the tri-state area pertaining to Medicare, Workers Compensation, Dual Coverage & Subrogation.
• Demonstrated outstanding communication abilities: writing, verbal & negotiating skills.
• Knowledge of Medicare & other insurance products.
• Demonstrated writing & reporting skills.
• 1yr in a customer service environment preferred.
• Background working w/ cross-functional teams preferred.
Primary Location: Maryland-Rockville-Regional Office 2101 E. Jefferson St.
Scheduled Hours (1-40): 40
Working Days: Mon-Fri
Working Hours Start: 8:00am
Working Hours End: 4:30pm
Schedule: Full time
Position category: Standard
Employee Status: Regular
Employee Group: Salaried Employees
Job Level: Individual Contributor
Job: Support Services
Public Department Name: Patient Financial Services
4 Year Degree
on Washington Post
Patient Financial Serv...
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