Saint Augustine, Florida
Claims Navigator Job Opening in Saint Augustine, Florida - Island Doctors, a Management Service Organization located in North and Central Florida, is seeking a Claims Navigator to review inpatient and outpatient hospital claims for its Medicare Advantage patients.
General Summary of Duties :
This person has responsibility for a combination of the following:
(1) Reviewing Island Doctors Medicare Advantage patients? in-house, outpatient radiology and same-day surgery claims for any inaccuracies prior to release to insurance company;
(2) Researching reimbursement rules and downloading accurate fee schedules for use with CMS pricers; and
(3) Developing methods for accurately valuing inpatient & outpatient claims matching contractual definitions, to include maintenance of supporting spreadsheets. Analytical skills, focus, accuracy and timeliness are paramount.
Essential Functions:
Research and define evaluation logic for Medicare Advantage hospital claims valuation
Locate and research CMS websites for adjudication rules
Download provider manuals, reimbursement policies and medical policies for use in hospital payer valuations
Create and maintain a schedule of download frequencies necessary for timely and accurate valuation of claims - maintain a schedule for updates
Manipulate fee schedules for loading into the contract management software program
Provide internal consulting for development of hospital claims scrubbing
Review patient claims to verify accuracy of claims valuation
Attend and participate in internal and external meetings as needed
Engage in process and quality improvement activities to minimize manual efforts
Other duties as required.
Education :
Bachelor?s degree or greater in related field, or equivalent combination of education and experience.
Experience :
Minimum of 2 years? experience working in the hospital industry
Hospital billing and/or claims management background required
Knowledge :
In-depth first-hand knowledge of Medicare adjudication methods and Prospective Payment Systems for inpatient and outpatient hospital claims
Demonstrated knowledge of coding conventions & the function of each: DRG Codes, Revenue Codes, Occurrence Codes, ICD-9, ICD-10, CPT and HCPCS codes
Knowledge of the various types of health insurance payers: 1) Medicare and 2) Medicare Advantage plans
Broad range knowledge of different types of providers, including facility versus non-facility based valuations
Intermediate Excel skills
Excellent communication skills
Healthcare reimbursement knowledge skills
Deductive reasoning and critical thinking skills
Job Type: Full-time
Required experience:
Claims Management: 2 years
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