Junior Knowledge Specialist

Job Description

Job title Knowledge Specialist (Band 5, Level 2)

Reports to Unit Manager / Asst Unit Manager

Under the supervision of the Claims Manager, the Senior Claims Examiner is responsible for analyzing and processing claims and meeting defined quality and productivity standards.

Process Skills:

• Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines
• Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims
• Accurately analyzes and interprets provider contracts
• Researches claims and makes appropriate adjustments
• Assists with system configuration and testing for new clients
• Assists with testing of new processes, and provides feedback
• Reviews and tests fee schedules
• Reviews and approves batch close reports for examiners
• Analyzes and authorizes high dollar claims
• Determines appropriate payment for claims submitted for reconsideration (payment appeals)

Behavioral Skills:

• Assists with training new or existing staff, as requested
• Responds to clients inquiries related to claims processing
• Communicates clearly and concisely, with sensitivity to the needs of others
• Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards; will support the success of the entire team; establishes and maintains effective working relationships with co-workers
• Follows all Policies and Procedures and HIPAA regulations
• Maintains a safe working environment
• Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
• Establishes and maintains effective working relationships with co-workers
• Participates in any required training sessions/seminars
• Participates in special projects as requested

Certification:

• Education/Experience – Educational requirements include a high school diploma or equivalent. Two to Three years of PACE plan management and/or claims processing knowledge required, along with current knowledge of Peak systems
• Requires working knowledge of ICD-10, CPT, Revenue, and HCPCS coding, along with understanding of APC and DRG reimbursement
• Requires knowledge of current computer technology, including the use of computers; knowledge and proficiency with associated software, including Excel and Word
• Skilled in establishing and maintaining effective working relationships with co-workers and clients
• Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
• Detail-oriented with ability to focus for extended periods
• Ability to work independently, seeking supervision as needed
• Ability to communicate professionally, clearly and effectively, verbally and in writing
• Ability to meet attendance requirements to effectively fulfill all functions of the position
• Ability to independently follow through on assigned tasks, without prompting
• Ability to prioritize effectively and multitask

Physical Demands & Requirements

• Communicates by way of the telephone with participants, customers, vendors and staff
• Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
• Remains stationary for extended periods of time
• Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects
• Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
• Frequent, repetitive use of hands/fingers entering information on a keyboard
• Occasional reaching to retrieve shelved item

Work Environment:

• This job operates in a home-office environment, or a professional office environment with a conversational noise level.
• No substantial exposure to adverse environmental conditions is expected
• Moderate pressure to meet scheduled appointments and deadlines
• Potential for occasional verbal aggression by clients and vendors