remote typeRemotelocationsWork From Home (HB)time typeFull timeposted onPosted Yesterdayjob requisition idR0051667
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Job Summary
This position includes a variety of claim administrative and technical tasks that support a Claim Unit and/or vendor staff, as well as the Claims Team and serves as a liaison for any internal departments.
In addition to these tasks, the Senior Claims Analyst is responsible for all of the same tasks as a Claim Analyst including the accurate adjudication and processing of medical, dental, vision, or other related claims, including related correspondence and/or electronic inquiries for assigned groups. All claims and inquiries are handled according to the established plan documents, claim processing guidelines, and established total turnaround times. Also advise team members regarding claim processing procedures.
Job Description o Resolve client, employee/member, or provider issues regarding escalated or complex claims. o Review and release over-authority claims up to limit specified by corporate policy. o Handle claim referrals, including pre-determinations, using internal and external resources as needed. Advice Claim Analysts and/or vendor regarding claim processing. o Handle network referrals as well as PPO repricing disputes. o Review, analyze and interpret claim forms and related documents. o Determine benefit coverage based on clinical edits, plan documents/booklets, benefit reference documents, Claim Reference Manuals and claims-related memoranda, and reports. o Appropriately investigate, pend and refer claims based on claim procedures and guidelines. o Accurately handle correspondence, claims, and referrals in the established timeframes and/or performance guarantees. o Support the Claims reinsurance team, in the research and resolution of claims as assigned o Handle complex or technical claim adjudication using internal and external resources as needed, e.g. transplants, experimental & investigational, chemotherapy, etc. o Research and respond to vendor reconciliation requests. o Mentor and assist with onboarding new Analysts, including the oversight of work o Support the management, monitoring, and tracking of performance in collaboration with the Supervisor. o Provide mentoring and coaching o Assist Supervisor in documenting processes for analysts o Other duties as needed/assigned
Required Job Qualifications: o High School diploma or GED equivalent o 3 years prior medical claim processing experience o Ability to work in a fast-paced, customer centric & production driven environment o Excellent verbal and written communication skills o Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff o Demonstrated critical thinking, to carry out instructions furnished in oral, written or diagram form o Flexible; open to continued process improvements o Self-directed individual who works well with minimal supervision o Good leadership, organizational and interpersonal skills o Ability to effectively handle with complex situations and reach resolution o Ability to analyze and interpret documents and Summary Plan Descriptions (SPDs) o Ability to adapt to various system platforms, and to effectively use MS Excel/Word
Preferred Job Qualifications: o Health Insurance/Third Party Administrator Experience o High School diploma or GED equivalent
Required Job Qualifications:
High School diploma or GED equivalent
3 years prior medical claim processing experience
Ability to work in a fast-paced, customer centric & production driven environment
Excellent verbal and written communication skills
Ability to work effectively with employees/members, providers, clients and differing levels of co-workers including Client Managers and all levels of staff
Demonstrated critical thinking, to carry out instructions furnished in oral, written or diagram form
Flexible; open to continued process improvements
Self-directed individual who works well with minimal supervision
Good leadership, organizational and interpersonal skills
Ability to effectively handle with complex situations and reach resolution
Ability to analyze and interpret documents and Summary Plan Descriptions (SPDs)
Ability to adapt to various system platforms, and to effectively use MS Excel/Word
Preferred Job Qualifications:
Health Insurance/Third Party Administrator Experience
Location: This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.
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EEO Statement:
We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.
Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.
We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.
JOB SUMMARY:Medical Reimbursement Specialists work with insurance carriers and patients to resolve outstanding balances through research, follow ups and appeals.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.
Edit and perform maintenance on Medicare claims.
Follow-up on billed claims in a timely and effective manner.
Maintain knowledge of current Medicare regulations and guidelines.
Monitor patient accounts for accurate payment.
Pursue account reimbursement through compliant action.
Edit rejected claims in DDE which are identified on RTP report.
Review patient bills for accuracy and completeness and obtaining any missing information.
Utilization and adherence to Medicare guidelines.
Other duties as assigned.
MINIMUM QUALIFICATIONS & REQUIREMENTS:
High School Diploma or GED equivalent
Two years (2) experience resolving medical Medicare claims
Knowledge of Medicare and/or Medicaid payors
Familiarity with CPT and ICD-10 coding preferred
Knowledge of insurance billing and medical terminology preferred
Familiarity with electronic and paper systems used in billing healthcare services
Ability to research unpaid or underpaid claims for resolution
PHYSICAL DEMANDS: Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines. A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.
About the Opportunity
At Machinify, we’re constantly reimagining what’s possible in our industry—creating disruptively simple, powerfully clear ways to maximize our clients’ financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions Team, you will, as a Claims Administrator, be responsible for supporting efficient claims processing and ensuring data accuracy throughout the review and auditing process. This role involves performing incoming claim reviews, organizing data, assigning statuses, and routing completed files to auditors while maintaining document hygiene and adhering to internal procedures.
The position requires close collaboration with internal teams to manage import queues, reconcile balances, validate charges, identify, and address errors, and facilitate claims routing. The Claims Administrator I oversee the intake and output of files, responding to inquiries, resolving discrepancies, and ensuring effective communication regarding claims.
Additionally, this role includes analyzing data trends, monitoring file-sharing processes, verifying data transfer accuracy, and ensuring appropriate volume levels are maintained. Data entry of documents and other administrative tasks are also integral to the position.
The ideal candidate demonstrates strong organizational skills, attention to detail, and the ability to work collaboratively in a dynamic environment.
What you’ll do
Review incoming claims, assign statuses, organize data, and route files to auditors.
Collaborate with teams to manage the import queue, reconcile balances, validate charges, correct errors, and route files.
Oversee file intake and output, addressing inquiries, discrepancies, and errors.
Analyze data trends and communicate updates on claims routing, efficiency, inventory, and volume.
Monitor file-sharing processes, ensure data transfer accuracy, and maintain appropriate volume levels.
Perform data entry and support additional administrative tasks as needed.
What experience you bring (Role Requirements)
Preferred experience in medical record review and knowledge of medical terminology.
Proficient in Microsoft Office Suite, Adobe Acrobat, and multi-monitor setups; adaptable to company-specific software.
Strong attention to detail, organizational, analytical, and critical thinking skills.
Excellent interpersonal and teamwork abilities, capable of collaborating across functions and driving change.
What Success Looks Like…
After 3 months
You will have a strong understanding of the role.
You begin building relationships and collaborating with peers.
You develop effective time and priorities management.
You receive initial feedback about your performance and are using it to improve.
You’ve gained confidence in your abilities and are starting to feel more comfortable in your role.
After 1 year
You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
You have established a strong network of internal relationships and are recognized as a key collaborator.
You’ve been entrusted with greater responsibility indicating the company’s confidence in your abilities.
You see opportunities for career progression and personal development.
Pay range: $24.00 USD per hour. This is a non-exempt position.
What’s in it for you
PTO, Paid Holidays, and Volunteer Days
Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
Tuition Reimbursement
Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.
We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.
JOB SUMMARY:Assist the Director of HIM in preparing claim audits, reviewing and recommending coding, revenue cycle and charge/billing changes on client hospital outpatient and Profee claims using proprietary software product. Use software to develop standardized reports, meet with clients, respond to coding questions in clear, concise, grammatically correct English, and provide support for other members of the revenue cycle consulting team. Client education, written FAQ answer preparation, and other duties as assigned.
This is a remote position
ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.
Reports To: Director of HIM/Audit Services (RCM Services)
Location: Remote USA; work from home office
FLSA Status: Full time, exempt
Summary: Assist the Director of HIM in preparing claim audits, reviewing and recommending coding, revenue cycle and charge/billing changes on client hospital outpatient and Profee claims using proprietary software product. Use software to develop standardized reports, meet with clients, respond to coding questions in clear, concise, grammatically correct English, and provide support for other members of the revenue cycle consulting team. Client education, written FAQ answer preparation, and other duties as assigned.
QUALIFICATIONS
5+ years of current directly related experience
Expert knowledge in revenue cycle and Outpatient coding (ER, SDS, OBS, ancillary, IR, Profee, E/M facility, I&I)
CCS, COC or CPC certification required
Medical Terminology and anatomy knowledge is required
Clinical Documentation and Inpatient coding experience is preferred. New hires will be expected to learn IP during employment.
Must have strong understanding of revenue cycle, CMS Manual/guidelines, Medicaid guidelines.
Strong Microsoft Excel, PowerPoint, Word and OneNote skills
Must have strong understanding of the Official Coding Guidelines, OP coding and billing (i.e. including but not limited to knowledge of rev codes, HCPCS, MUE and CCI edits, UoS and ICD-10 CM)
Strong analytical capability, independent thinker and good decision-making skills
Excellent written and verbal communication and presentation skills
Strong computer and technology knowledge and skills
Highly professional demeanor, great client satisfaction skills
ESSENTIAL DUTIES AND RESPONSIBILITIES
Become proficient in the use of the PARA Data Editor, our proprietary software;
Select and review claims for review based on trends/data analysis in the PARA Data Editor; organize information and access to medical documentation.
Audit all aspects of claim including (but not limited to):
-Omitted or incorrect charges,
-Review OPPS and CAH charges and apply guidelines.
-CMS/Payer specific guidelines
-Coding accuracy for ICD-10 CM, CPT/HCPCS (including but not
limited to 10000-69999, 80000, 90000, J codes, G codes, Q codes,etc)
-Departmental review for inaccuracies, omitted data/documentation
and charges
-NCCI edits, MUE edits, Medi-cal and Medicare guidelines/CMS
Manual guidance,
-Units of services
-E/M Profee/Facility
-Units of services
-Documentation improvement.
Assist in preparing written documents for publication under the direction of the Director, HIM, i.e., Q&A entries.
Develop a working understanding of the outpatient hospital reimbursement process, including documentation, coding, and billing.
Participate in presentations to clients and prospective clients, typically over web meetings.
Develop and maintain the skills and knowledge necessary related to the assigned specialty areas and the related services. Keep current on all related information from journals and bulletins. Distribute and pass on all necessary materials, including copying for reference files when relevant.
Maintain current certifications and accreditations (as applicable).
Research new guidelines, data elements, payer specifications, etc.
Other duties may be assigned as necessary.
This is a remote position
PHYSICAL DEMANDS: Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines. A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.
The Billing Charge Entry Specialist II – RCM supports and promotes charge entry demographic processes, including troubleshooting mismatched records, validating accurate registration through escalation processes, or completing specialty registration, manual document extraction, and ensuring accurate billing to prevent revenue leakage.
At this time, US Anesthesia Partners does not hire candidates residing in California, Hawaii, or Alaska.
The base pay estimate for this role is $16.49 – $26.39 hourly. The final offer will depend on the skills, experience, and qualifications of the selected candidate. This range is for base pay only and does not include bonuses or other compensation. This position is eligible for a quarterly bonus. Bonuses are not guaranteed and are awarded based on company and individual performance.
Job Highlights
ESSENTIAL DUTIES AND RESPONSIBILITIES: (The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation)
Supports core demographic production teams through escalation and clarification.
Troubleshoots cases as needed to determine the appropriate course of action, including escalation when necessary.
Reviews escalated charge tickets to ensure accuracy of supporting details and proper registration.
Manually extracts and attaches required documentation from external billing systems when necessary.
Contacts facilities as needed to obtain necessary information to ensure accurate and complete case billing.
Maintains strictest confidentiality.
Performs other duties as assigned.
Qualifications
KNOWLEDGE/SKILLS/ABILITIES (KSAs):
High school diploma or equivalent required.
Billing experience in a healthcare organization preferred.
Minimum of 2 years’ experience in a healthcare business office.
Knowledge of organizational policies, procedures, and systems.
Experience collecting, organizing, and reporting information.
Computer applications skills including MS Word and Excel.
Keyboarding/data entry skills.
Verbal and written communication skills.
Must have a pleasant disposition and be a team player.
Ability to read, write, and speak English.
Ability to communicate well with the public.
Ability to work independently with limited supervision.
Ability to work effectively with staff, physicians, and external customers.
Ability to meet minimum production and quality requirements once initial training is complete.
*The physical demands described here are representative of those that may need to be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
Occasional Standing
Occasional Walking
Frequent Sitting
Frequent hand, finger movement
Use office equipment (in office or remote)
Communicate verbally and in writing
US Anesthesia Partners, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, status as a parent, national origin, age, disability (physical or mental), family medical history or genetic information, political affiliation, military service, or other non-merit based factors.
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