Claims Coordinator (Hybrid - Troy, MI) - Health Alliance Plan - Henry Ford Health System

General Summary:


Utilize claims adjudication and investigative experience to support claim administration functions and handling of priority provider focused claim projects. Collaborate with department leaders and staff on claim adjustment and recovery initiatives including system-automated processes. Develop and implement new internal procedures and new system release testing initiatives.


Principal Duties and Responsibilities:



+ Execute submitted Mass Claim Adjustment Request Forms (MCARF) requests and analyze the best means to execute the approved request, including; execute the Facets mass claim adjustment jobs and manage the fallout of claims to ensure proper resolution, and coordinate execution of external programs to copy reload claims through 837 files. Update the MCARF with the claim outcomes for each executed job through inventory tracking repository

to inform internal customers who submitted the requests.


+ Resolves claims, conducts formal account reviews, identifies lost charge recovery, analyzes and documents delays and payment variances.


+ Analyze Provider Claim data to reconcile accounts submitted by hospitals or physicians through a data reconciliation program. Provide results to requestor. Assist in formulating plans to develop an ongoing process to identify opportunities for recovering erroneous or fraudulent claims.


+ Analyze various payment issues and make recommendations to the appropriate departments including Finance and IT for improvements. Work with providers to collect monies due to HAP in cases of overpayments. Makes collection contacts to delinquent accounts and performs any tasks or duties in

order to aid in collection of past due or overdrawn accounts.


+ Acts as a project team lead, specifically on developing and defining requirements and testing activities. Participate in User Acceptance Testing (UAT) and system testing for computer application releases, make recommendations as needed.


+ Conduct Division Performance Monitoring and analyze claims data to design and evaluate quality measurements and improvement programs. Monitor the progress of these improvements. This includes the automated release programs, unposted workgroups and results of corporate audit recommendations.


+ Provide guidance, assistance, coordination and follow-up on complex problems by investigating all options and ensures resolution.


+ Investigate, evaluate, and create documentation of Claims Department policies, procedures and job aids.


+ Assist with medical and hospital claim entry and high dollar claim review.


+ Other duties as assigned.




Education/Experience Required:



+ Associates Degree


+ Related and relevant experience may be considered in lieu of academic requirements. Related experience is defined as four (4) years’ experience in claims adjudication, claim inquiry resolution, and/or claim adjustment experience.


+ Three (3) years’ experience adjudicating claims.


+ One (1) year experience processing claims including claim adjustments.


+ Two (2) years’ experience investigating and processing claim inquiries.


+ One (1) year experience processing claim adjustments.


+ Minimum three (3) years of claim financial audit experience.


+ Minimum five (5) years’ experience working in the health care industry.


+ Knowledge of CPT, HCPCS, and ICD-10 coding systems and working knowledge of healthcare compliance are required.


+ Strong MS Office skills including Advanced Excel - ability to create your own spread sheets and manipulate information as needed.



Preferred:



+ One (1) year experience processing Pega cases.


+ One (1) year experience processing Facets claims and adjustments.


+ Experience with Cognos query and reporting.


+ Experience with Power BI reporting.


+ Experience using MS Office 365, including Outlook and TEAMs.


+ Database management.


+ Minimum one (1) year Customer Service Call Center experience.



Skills and Abilities:



+ Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related projects.


+ Demonstrated ability to collect and prepare data for written/oral presentations.


+ Demonstrated ability to communicate effectively.


+ Ability to interact with outside sources and maintain professional contacts.


+ Excellent written and verbal communication skills are essential.


+ Must be able to work effectively with persons of varying position levels and diverse interests.


+ Understanding of healthcare industry and managed care concepts.


+ Knowledge of a table driven claims processing system.


+ Knowledge of Windows, Microsoft Excel and Word, Query Tools (COGNOS, etc.), Power BI and Implementation/Administration of Packaged Claims Processing Applications.


+ A high level of human relations skills.


+ Ability to adapt to a constantly changing environment.





Additional Information



+ Organization: HAP (Health Alliance Plan)


+ Department: Payment Integrity


+ Shift: Day Job


+ Union Code: Not Applicable












Additional Details


This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.








Overview


Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .








Benefits





The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.








Equal Employment Opportunity/Affirmative Action Employer


Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is


committed to the hiring, advancement and fair treatment of all individuals without regard to


race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,


weight, marital status, family status, gender identity, sexual orientation, and genetic information,


or any other protected status in accordance with applicable federal and state laws.