Department: Health and Human Services (IMCare/County Based Purchasing Division)
Classification: Grade 7 (Local 580)
FLSA Status: Non-Exempt Position Description: Administrative Support; Technical/support work – detailed claims processing and system knowledge required for both Medicaid and Medicare.
Current Vacancy: One (1) Regular, F/T position
Open Competitive Job Opportunity : Open to applicants of the public.
1. Claims Processing: a. Receive medical services claims from providers, scan, image and enter data into IMCare claims processing program. b. Verify data; resolve system edits. c. Research claim problems/inconsistencies; adjudicate claims per appropriate provider type and group association. d. Audit claim payment amounts with MHCP benefit sets and provider reimbursement fee schedules. e. Follow claims processing operational controls and quality assurance audit criteria. f. Audit adjudicated claims, prepare provider reimbursement checks and claim detail remittance reports. g. Process claim adjustments, refunds and voids. h. Work closely with the data system support staff to resolve any program problems and participate in initiating programming requests for special fee schedules, provider set-up and reimbursement, and State contract requirements and changes. i. Produce claims processing reports.
2. Provider Customer Service: a. Work with medical provider offices in resolution of claims problems. b. Educate providers regarding claim submission requirements and benefit level changes as necessary. c. Train providers to use web-based inquiry programs as
available to assist them with member eligibility
verifications, claims status inquiry, and authorization
submission as applicable.
3. Computer Systems: a. Work with multiple complex State, local and program specific data systems. b. Enter data, verify and reconcile claims and accounting data. c. Query data system as necessary to produce custom reports and statistics. d. Maintain and update member records, provider set-up, benefit sets, and fee schedules, etc. as needed. e. Coordinate electronic data file transfers between the State, IMCare data system and pharmacy benefit manager data system. f. Verify and audit MHCP eligibility with IMCare member enrollment. g. Update the crosswalk of State tuple indicies to IMCare rate cells as program and benefit changes are made by the State. h. Reconcile IMCare member enrollment with capitation revenue. i. Develop and maintain tracking worksheets on pc programs, audit data, design and prepare reports. j. Research and assist in the correction of any data system discrepancies between the various modules of software programs. k. Work closely with data system vendor support staff.
4. Contract Compliance/Utilization Review: a. Collect data from claims processing reports and data warehouse queries and work closely with other staff in monitoring enrollee and provider utilization. b. Analyze data and follow-up with providers as indicated. c. Prepare and submit reports to DHS as assigned. d. Assist with preparation of capitation rate proposals and
participate in DHS contract negotiation sessions.
5. Provider Contracts: a. Assist in updating/revising provider service agreements as necessary per federal, state and DHH contract requirements. b. Send the applicable provider contracting packets to providers per their individual provider type and participation status, track return of signatures and required associated documents. c. Maintain the provider listing; submit to the State as
6. Accounting: a. Code, record and reconcile receipts, disbursements, journal entries and other financial transactions. b. Process accounts payable separately from claims processing. c. Audit, correct or reconcile any accounting errors and
7. General: a. Work as a team member with co-workers in staff meetings, special projects, program revisions, and in drafting policies, procedures, provider updates and other program materials. b. Attend/participate in DHS scheduled meetings and
8. Regular attendance on the job.
9. Perform other duties as delegated.
Essential Function(s): The basic job duties that an employee must be able to perform, with or without reasonable accommodations. If the position exists to perform that duty, it is an essential function. The essential function(s) for this position are 1 - 8 of the above Duties.
Non-Essential Function(s): Marginal duties that have limited or no consequences should the duties not be performed by the particular position. The non-essential function(s) for this position are 9 of the above Duties.
% of Time: 60% Duty 1; 20% Duty 2; 10% Duty 3; 3% Duty 4; 2% Duty 5; 3% Duty 6; 2% Duty 7
Minimum Qualifications (Pass/Fail): High school graduate OR equivalent; two (2) year’s work experience, within the past five (5) years, with medical claims coding in a medical provider office, public agency, insurance company, medical claims service or health related business OR two (2) year’s work experience, within the past five (5) years, with claims processing in a healthcare environment OR completed a vocational course in Medical Coding and Billing, Insurance Coding Specialist or Medical Secretary ( must attach t ranscript ) PLUS one (1) year work experience, within the past five (5) years, in medical claims or healthcare claims processing; computer education ( must attach transcript ) and/or work experience; valid driver’s license and reliable means of transportation; successfully pass a Medical Accounting Technician Exam, obtaining 70% or higher, which will be administered after the closing date and time of the position. Knowledge, Skills & Abilities: Excellent time management skills; be detail oriented and perform tasks with accuracy; strong analytical skills, excellent written and verbal communication skills and a professional customer service attitude; flexibility to work in a team environment. Ability to: enter and reconcile data, prepare reports, complete forms and develop tracking systems; understand medical benefits and coordination of benefits in order to process claims with a high degree of accuracy; work with multiple data systems; comprehend and apply complex rules, policies, and procedures and abide by applicable State and Federal managed care regulations; adapt to change; work well with others; ability and willingness to follow rules and procedures and directives from supervisors. Preference for: Work experience with multiple coding schemes (ICD-9, CPT, HCPCS and DRG); work experience with multiple standard claim forms (CMS/HCFA-1500, UB-92 and ADA); education ( must attach transcript) and/or work experience with Word, Excel, Access; claims processing work experience in a healthcare environment (beyond the minimums); work experience (beyond the minimums) with medical claims coding in a medical provider office, public agency, insurance company, medical claims service or related business; education ( must attach transcript ) (beyond the minimums) in Medical Coding, Insurance Coding Specialist or Medical Secretary.
WORK HOURS, LOCATION, CONDITIONS AND EXTENT OF SUPERVISION :
Work Hours: The normal hours of work shall be eight (8) hours per day and forty (40) hours per week, Monday - Friday 8:00 am - 4:30 pm, overtime as necessary and approved.
Work Location: Itasca County Health and Human Services Department, Itasca Resource Center, 1209 SE 2nd Ave, Grand Rapids, MN
Work Conditions: These working conditions are a summary; review of the job duty analysis will provide more detailed description. CONTINUOUSLY: sitting, sensory (vision). FREQUENTLY: sensory (hearing, talk/speak). OCCASIONALLY: lift (low-level under 10 lbs), lift (mid-range under 10 lbs), lift (overhead under 10 lbs).
Extent of Supervision: Work is performed under the direct supervision of the County Based Purchasing Division Manager, indirect supervision of the IMCare Associate Director, Health and Human Services Director. Supervision of Others: none