Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina. In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.
The Claims Coordinator is responsible for the timely processing and claim distribution of both new and reconsideration claims within all LOB’s for Clear Spring Health. Clear Spring Health is committed to providing a high-level of customer service to our internal and external customers that meet our departmental service level agreements while educating the customers accurately on our products, procedures and regulations. This position must be customer focused (internal and external): adapting to different customer styles, making sure that each claimant's needs are fully understood and taking the appropriate action to meet and exceed the customer's expectations.
Accurately provide information to all incoming inquiries regarding claims, disputes, claim information, procedures, and regulations
Efficiently maneuvering through various computer systems and on-line resources in retrieving claim information while responding to customer inquiries
Partner with our internal and external business partners, when required, in order to resolve claims related inquiries
Review claim requests and respond within established service level agreements
Assists in managing departmental claim activities to ensure that payouts are adjudicated in an accurate and efficient manner
Effectively ensure that detailed electronic records are maintained by accurately documenting all actions taken.
Meeting measurable department standards as they relate to call quality, claim accuracy and efficiency measures as well as meeting teamwork, ownership, and professional development goals
Learning, retaining, and updating one's knowledge of a wide variety of product information and internal processes and procedures, while adhering to strict industry rules and regulations.
Takes ownership of customer claims by following requests through to completion and notifying appropriate personnel if problems exists.
Display a positive attitude while adapting and being receptive to change
Takes initiative in learning more by asking questions; investigating error sources to avoid future mistakes; making the best use of time
Excel in a culture that involves ongoing coaching and feedback from a variety of sources, in order to ensure the customer’s needs are met
Display actions that align with our Vision, Mission, and Values
Submit claim data accurately and timely, in alignment with departmental production and quality goals
Maintain established levels for accuracy and productivity
Pre-screen all claim types for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding)
Correctly adjudicate claims for contracted/non-contracted providers; Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with contractual guidelines
Review respective coding (i.e. CPT, HCPCS, ICD-10) to ensure that claims are billed in compliance with CMS and Correct Coding guidelines
Verify presence of all required data fields and that applicable medical records are included/reviewed (where required)
Identify, log and handle third party liability (TPL) or coordination of benefits (COB) issues
Refer claims for medical claim review as necessary/applicable
Identify and refer potential fraud and abuse cases to the Compliance Department
Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs
Identify opportunities for claims adjudication process improvements
Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
Ability to read, write and communicate at a professional level
Effective time management and organizational skills
Effective interpersonal and communication skills
Other duties and responsibilities as may be assigned
Associated degree preferred or equivalent experience
Minimum of 1 years of experience in healthcare claims processing, or an equivalent combination of education, training and experience
Computer proficiency in a Windows environment, knowledge of Microsoft Office products