Claims Analyst at MetroPlus

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Responsible for investigating and resolving high level claims-related issues and possess deep understanding an various reimbursement methodologies.

• Improves the level of engagement between the Plan and Hospital Network, Ancillary and Community providers by providing timely resolution of issues and providing outstanding customer service and support
• Detailed understanding of various reimbursement methodologies (i.e., skilled nursing facilities, medical group, post-acute bundles, etc.,)
• Conducts audits to review accuracy of cost reports and payment of claims
• Reviews inquiries from providers regarding cost report settlements
• Researches and analyzes claim processing outcomes, identifies issues and reports as necessary, and proactively outreaches to peers, supervisor, and/or providers upon findings
• Prepares and analyzes cost/business proposals and reports of findings; makes recommendations to management
• Applies knowledge of established procedures to research and resolve escalated customer questions or management requests
• Acts as the initial contact for escalated issues from the support staff and escalates only the most complex issues to the immediate supervisor
• Liases between Finance, Network Operations, claims, UM, Provider Maintenance, Core and Contracting departments to resolve ongoing issues and determines root cause and ultimately, resolution of issues
• Reviews system setup to determine if it reflects contract language and outreaches to the Contracting Department for assistance
• Attend Joint Operating Committee meetings and takes ownership of resolving issues with assigned hospitals, etc.
• Contributes to development of policies and procedures, process improvement initiatives
• Performs other support activities and duties as assigned

• Requires a Bachelor’s degree
• 3-5 years experience in a managed care government program claims processing/analyzing experience, working with providers in addressing reimbursement issues
• Or an Associate Degree with 5-7 years or more experience in a managed care government program claims processing/analyzing experience, working with providers in addressing reimbursement issues
• Ability to work independently to meet deadlines
• Working knowledge of and proficiency with Windows-based PC systems and Microsoft Word, Outlook, Excel, and PowerPoint, Sharepoint
• Ability to exercise tact and diplomacy and demonstrate strong customer service skills
• Ability to prepare written and oral reports and make effective presentations
• Ability to independently manage assigned workload, make decisions related to area of functional responsibility, and recognize issues requiring escalation
• Highly organized, detail oriented, dependable and professional individual
• Ability to travel to meet with Providers and their representatives

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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