Claims Project Associate (Hybrid - Troy, MI) - Health Alliance Plan

GENERAL SUMMARY:

Under minimal supervision provide assistance to the Claims Project Analyst to support medical coding (ICD-9, ICD-10, HCPCS, CPT, DRG, and DSM)
to a variety of internal departments. Serve as the secondary contact for ClaimsXten including providing medical coding expertise, quality assurance, education and training initiatives for the Claim Operations Division.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Provide project support under the direction of the Claims Project Analyst for the claims division on corporate initiatives.
• Identify, investigate, and resolve related system and data management errors that impact MA adjustment.
• Assist Claims Project Analyst with CSC/CMS audits and complaints.
• Assist Claims Project Analyst in guiding support analysts in performing routine assignments, ad-hoc projects, and meeting established deadlines relating to Medicare and ClaimsXten appeals.
• Assist Claims Project Analyst in participating in system and process development, including testing.
• Support the Claims Project Analyst in developing/executing processes to ensure medical codes used within Payer processes are identified, updated, approved, and implemented.
• Investigate and resolve workflow holds related to ClaimsXten editing and make code editing recommendations to the Claims Project Analyst.
• Manage the Clinical Code Editing Pega workbasket for cases related to ClaimsXten appeals.
• Execute ClaimsXten reports created in Cognos, resolve the claims until Xten automation is implemented.
• Participate in weekly ClaimsXten meetings, along with the Claims Project Analyst, to support updates and CRA implementation.
• Perform other related duties as assigned.