Senior Claims Analyst

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit https://www.amidacareny.org/about-us/careers/ for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced individual to join our team as the Senior Claims Analyst. Compensation will be commensurate with experience.

Position Summary:

The Senior Claims Analyst assists management to ensure accurate, timely and proper execution of claims. Assists in quality control and accuracy for claims payments performed by Amida Care's Third-Party Administrator and other specialty vendors. This position will identify opportunities and challenges associated with the end-to-end claims processing life cycle and provide support and resolution to issues This role is also responsible for the proper resolution of provider claim appeals/inquiries and correspondence received by the plan to ensure provider satisfaction.

Responsibilities:

• Ensure accurate reimbursement in accordance with Amida Care Provider Contracts for both NYS Medicaid and CMS Medicare, in regard to configuration and implementation of the Third-Party Administrators' claims processing system.
• Enter and track provider inquiries/appeals and written correspondence and collaborate internally and with Amida Care's Third-Party Administrator and specialty vendors to provide resolution to ensure provider satisfaction. Identify trends to resolve claim payment issues. and systemic gaps.
• Responsible for scanning all written correspondence and medical records received for High Dollar claim processing.
• Assist Manager and Director to obtain weekly appeals inventory dashboard along with analysis on improving claims appeals turnaround time.
• Monitor and track governmental agencies for updates to annual and quarterly physician fee schedule updates and oversee the accurate and timely implementation into the Third-Party Administrator claims processing system. Assist with QA effort as appropriate.
• Research claims processing guidelines, provider contracts, fee schedules, to determine root cause of payment error.
• Work with internal departments to resolve provider claim and reimbursement challenges. Ensure providers are billing in accordance with contractual terms.

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

EDUCATION REQUIRED

• High School Diploma or GED.

EXPERIENCES AND/OR SKILLS REQUIRED

• Five years in a NYS Medicaid Health Plan with strong claims processing and analytical experience. (Required)
• Knowledge of claims processing rules and coding knowledge of DRG, ICD10 and CPT4 (Required)
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) (Required)
• Knowledge of HIPAA guidelines (Required)
• Ability to manage multiple simultaneous priorities and meet deadlines (Required)
• Strong communications skills (verbal, written, presentation, interpersonal) (Required)
• Excellent attention to detail, judgment, analytical, and problem-solving skills (Required)
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values.