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Contestation Specialist in Miami, Florida at Community Medical Group

NewJob Function: Admin/Clerical/Secretarial
Community Medical Group
Miami, Florida, 33126, United States
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Job Description

Summary

The Contestation Specialist will review medical and pharmacy claims, eligibilities and supporting medical documents to identify contestation and recovery opportunities with the Health Plans. Will also monitor, track and report success of the contestation process.

Duties and Responsibilities

  1. Review medical and pharmacy claims data, eligibility files, and medical documents to identify opportunities for contestation.
  2. Responsible for creating, improving and maintaining contestation Policy and Procedures.
  3. Responsible for tracking and monitoring on a weekly/monthly basis eligible claim for contestation.
  4. Establish good and effective communication with Health Plans.
  5. Submit contestation requests and support documentations to Health Plans within established filing deadlines and contractual requirements.
  6. Work closely with Network and Contracting department to review and recommend changes based on claims behavior.
  7. Report to Network and Contracting open contestation cases, recoveries, aging, trends, and financial impact.
  8. Create and maintain a set of tracking reporting.
  9. Analyze complex healthcare claims, eligibility, and pharmacy data regarding healthcare costs and utilization and make recommendations based on relevant findings.
  10. Keep record of contestation submissions, supporting evidence, correspondence, recoveries, and payment outcomes.
  11. Ensure compliance with Health Plan requirements, contractual obligations, regulatory guidelines, and internal policies related to contestation activities.
  12. Perform other duties as assigned.

Qualifications

Education/Experience:

  1. Bachelor’s degree in business, finance, computer science, engineering, economics or related field preferred.
  2. At least 3-5 years of professional experience in claims-based healthcare analytics with a payer, provider, or related healthcare entity. Value-based care experience preferred.
  3. Certified Subrogation Recovery Professional (CSRP) certification is a plus.
  4. Familiarity with healthcare reimbursement methodologies and calculations such as DRGs, Revenue Codes, CPT Codes, bundled payments, etc.
  5. Knowledge of health insurance financial business cycle, healthcare quality reporting, and benchmarking.
  6. Knowledge of healthcare claims; differences between institutional vs professional billing and various sites of care/service
  7. Advanced or higher proficiency in Microsoft Excel.
  8. Experience with Power BI, Tableau, or Microsoft SQL preferred.
  9. Bi-lingual Spanish/English preferred.

Skills:

  1. Possess personal qualities of integrity, credibility, and commitment to corporate mission.
  2. Thoroughness and attention to detail.
  3. Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines and standard accepted practices.
  4. Excellent people skills, with an ability to partner with a dynamic leadership team.
  5. Flexible and able to multitask; can work within an ambiguous, fast-moving environment, while also driving toward clarity and solutions; demonstrated resourcefulness in setting priorities and guiding investment in people and systems.
  6. Ability to work with individuals within and outside the organization, in professional and courteous manner.
  7. Demonstrated ability to successfully plan, organize and manage projects.
  8. Organized and able to manage competing priorities.
  9. Resourcefulness in problem solving.
  10. Detail and financial oriented.
  11. Strong written and verbal communications skills.
  12. Must be highly flexible; able to accommodate changing needs of the department.

Nature of Work

  1. Job duties require exercise of discretion in selecting from established alternatives to situations which arise on the job.
  2. May be required to perform duties and responsibilities not listed in this description, on a temporary or long-term basis.

Job Location

Miami, Florida, 33126, United States

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