General Summary of PositionUtilizes departmental software programs, including Microsoft Word to compose reports from data analysis, Microsoft PowerPoint to present comprehensive visuals, and Microsoft Excel to convert data from text files into an importable format to transfer data to a Microsoft Access database or a Microsoft Excel spreadsheet. Completes reconciliations of Excel spreadsheets to ensure data is accurate. Prepares and submits various daily, weekly, and monthly departmental reports for oversight using Microsoft Excel and other tools as assigned. Utilizes Microsoft Excel and other organization-based reporting tools and applications to abstract, create, provide detail, summarize, and trend data per departmental requests. Supports the MedStar Family Choice Department of Appeals/Grievances/ER Reviews for Maryland Appeals and Grievances, and DC Appeals by building/updating dashboards and reports using Tableau, SQL Server Reporting Services, and other systems interfacing with and required to build reports including advanced data visualizations and interactive features in Tableau. Specifically, position responsibilities include data collection requirements for reports and dashboards, acquiring and managing datasets, developing and publishing reports and dashboards, performing ad hoc analysis, composing report summaries, and delivering data-driven suggestions based on their findings to the Manager of Appeals/Grievances/ER Reviews for oversight. Consults directly with business users, clinicians, analysts, and decision-makers to gather reporting requirements and translate business requirements into functional specifications to implement and update reports and dashboards.Manages Maryland and District of Columbia member/enrollee and provider medical appeals, complaints, and grievances. Responsible for member/enrollee advocate functions. Interacts directly with members/enrollees, staff, physicians, and others on the telephone to resolve issues. Acts as a resource and documents all information as it relates to medical appeals, complaints, and grievances. Assists with the collection of quality improvement information via telephone. Responsible for accurate computer data input, tracking, trending, clerical, survey processing, outbound calls, and correspondence as expected.We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels. Primary Duties and Responsibilities <li>Attends training sessions and workshops offered. Attends and successfully completes required annual mandatory training (SITEL) within the defined time frame.</li><li>Keeps abreast of regulatory and specific changes as it relates to reporting requirements.</li><li>Achieves established monthly goals as related to specific benchmark reporting.</li><li>Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.</li><li>Maintains established daily performance benchmarks and meets the established productivity standard for the department.</li><li>Meets monthly departmental key performance indicators (KPIs) as they apply to daily, weekly, and monthly reporting deadlines.</li><li>Attends off-site meetings as required.</li><li>Based on the HIPAA Privacy Rule, Security Rule, and Breach Notification Rule, conducts case-related research in the computer system for business purposes only. Correctly categorizes inquiries/complaints and refers cases appropriately to other departments for follow-up; i.e. provider issues, or quality of care issues. Tracks all inquiries or complaints to ensure that cases are resolved within State-required timeframes. Documents resolution and prepares and sends written correspondence in response to members initiating complaints within State / NCQA required timeframes.</li><li>Attends required meetings and participates on committees as directed and expected.</li><li>Coordinates the processing of medical appeals. Evaluates, investigates, and prepares appeals by requesting/obtaining clinical information from providers via fax, mail, and telephone. Must ensure that providers have submitted appeal requests timely. Generates appeal acknowledgment letters and resolution letters per DHMH / District of Columbia regulations. Forwards appeal and related clinical information to the assigned Physician Advisor for determination.</li><li>Demonstrates behavior consistent with MedStar Health's mission, vision, goals, objectives, and member care philosophy.</li><li>Documents all pertinent clinical information in the computer system per policy with accuracy. Works collaboratively with appropriate department staff, and administrative and clinical personnel when appropriate. Completes denial/appeal response form and forwards to administrative staff to generate appeal letter. Ensures that appeal determination correspondence is mailed within DHMH, District of Columbia and NCQA required timeframes.</li><li>Effectively conducts interviews with the members/enrollees, family members, or providers, and collaborates with appropriate department staff and clinical personnel as deemed necessary and assists the member in coordinating care or services when requested or required. Evaluate, investigate, and resolve complaints by obtaining background information and data.</li><li>Process telephone calls from providers, other department staff, and members/enrollees in regard to complaints, compliments, grievance procedures, denials, and appeals.</li><li>Responsible for ensuring all Maryland and District of Columbia clinical information related to medical appeals is scanned and attached to the appropriate event in the computer system.</li><li>Triages all incoming appeal requests via mail, fax, etc. Responsible for forwarding all appeal requests to appropriate team members or departments for timely processing.</li><li>Triages provider inquiries regarding claim denials and payments and redirects to MFC Claims Auditing Dept or MFC Claims TPA to process provider inquiries.</li><li>Works collaboratively with the Claims Auditor to ensure that payments by the MFC TPA are paid correctly based on fee schedules and applied business rules. Shares expertise with superiors and colleagues and provides suggestions for department process improvement efforts.</li><li>Routinely performs self-evaluations and practices self-awareness to maintain and improve work expectations.</li> Minimum Qualifications Education<ul><li>High School Diploma or GEDrequiredand</li><li>Associate's degree Computer science, analytics, or a related field. required</li><li>One year of relevant education may be substituted for one year of required work experience.</li></ul> Experience<ul><li>3-4 years At least 3-4 years of analytics and data visualization experience, with a demonstrated ability to query, clean, blend, validate aggregate, and analyze large datasets to create and update reports and dashboards. requiredand</li><li>3-4 years Customer service experience in a managed care or social service setting requiredand</li><li>3-4 years Medical appeals processing, medical billing claims, auditing, and COB experience. preferredand</li><li>3-4 years Demonstrates ability to create advanced data visualizations in Tableau and SQL is preferred. Experience with relational databases and SQL. preferred</li><li>One year of relevant professional-level work experience may be substituted for one year of required education.</li></ul> Knowledge, Skills, and Abilities<ul><li>Detail oriented, excellent verbal and written communication and organizational skills</li><li>Under general supervision of the Grievance and Appeals Manager performs a variety of complex, responsible and confidential duties requiring a thorough knowledge of organizational procedures and precedents perform routine clerical, administrative duties in support of the Grievance and Appeal Department.</li><li>Attention to detail.</li><li>Excellent time management and organizational skills ability to manage high volume of work assignments effectively </li><li>Strong analytical and research skills.</li><li>Ability to type 40 words per minute.</li><li>Filing skills.</li><li>Knowledge of claims processing and medical billing.</li><li>Knowledge of managed care/healthcare industry preferred.</li><li>Ability to process complex business rules simultaneously to render decisions.</li><li>Logical reasoning and deduction skills for error and problem resolution.</li><li>Excellent interpersonal and customer service skills.</li><li>Strong quantitative analytic skills with an aptitude for analyzing large data sets.</li><li>High proficiency with data management and visualization tools such as SQL and Tableau.</li><li>Solid working knowledge of word processing, spread sheet and database management computer software and applications.</li><li>Passion for analytics with the desire to help drive immediate improvement in business results based on the dataanalysis.</li><li>Proven ability to prioritize work, manage multiple competing priorities, and work in a fast-paced environment with a high volume of time-sensitive information.</li><li>Ability to work effectively independently, work with very little supervision and in a team environment.</li></ul> Why MedStar Health? At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through: <ul><li> Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.</li><li> Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities.We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.</li><li> Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.</li><li> More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.</li></ul> About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people. MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.

General Summary of Position Remote schedule. Selected candidate must be local to the DMV area to work on-site in Washington, DC 1 - 2 days per month plus for special projects. Job Summary - Analyzes invoice with no adjudication status to facilitate timely reimbursement for 1 billion + annual billing of provider services. Reviews, researches, and corrects TES edits, eligibility and registration corrections. Ensures that claims meet billing guidelines for assigned carriers. Uses GE IDX ETM to ensure the claims status is changed to ensure successful resubmission in a timely manner. Primary Duties and Responsibilities <li>Contacts third party payers as needed to resolve billing problems/claims processing delays.</li><li>Exemplifies Guest and Staff Relations standards in all activities in areas of service, resource utilization, high quality outcomes and effective communication and holds staff accountable for conformity with those standards in all activities.</li><li>Maintains billing manuals and reference documents for assigned third party carriers.</li><li>Processes high volume claim submissions with an error rate of 10% and less.</li><li>Recommends and assists in implementation of manual and automated billing processes to enhance claim generation and submission process.</li><li>Researches and requests necessary billing information and documentation from provider/division billing contact/patient.</li><li>Resolves all No Activity invoices accurately and in a timely manner.</li><li>Responds to incoming mail from insurance carriers.</li><li>Reviews and resolves claim issues such as edits and registration edits in a timely manner.</li><li>Reviews claim forms to meet billing requirements as dictated by third party payers.</li><li>Reviews, processes, or reassigns appeals, charge correction, coding and provider enrollment rejections as required to achieve successful claim reimbursement.</li><li>Serves as resource to others related to assigned insurance carriers as needed.</li><li>Updates accounts in billing system.</li><li>Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.</li> Minimum Qualifications Education<ul><li>High School Diploma or GED equivalent required</li></ul> Experience<ul><li>1-2 years medical billing environment required </li><li> GE IDX experience preferred</li></ul> Knowledge, Skills, and Abilities<ul><li>Knowledge of accounts receivable practices.</li><li>Strong organizational skills with the ability to process high volume services, with accuracy on a daily basis.</li><li>Skills in using computer and calculator.</li><li>Ability to examine documents for accuracy and completeness and prepare claims and other records according to detailed instructions.</li><li>Ability to work and thrive in team oriented, production and deadline driven work environment.</li><li>Verbal and written communication.</li></ul> Why MedStar Health? At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through: <ul><li> Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.</li><li> Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities.We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.</li><li> Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.</li><li> More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.</li></ul> About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people. MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.

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Medstar Health Jobs

Medical Appeals Grievance Reporting AnalystMay 8, 2024

Claims Research Analyst Physicians BillingMay 2, 2024

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