ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.

POSITION SUMMARY

This position is responsible for assuring the accuracy, completeness and appropriateness of claim determinations and payments for Independent Living Systems/Royal Health Care clients.

Functions include, but are not limited to, claims testing and processing including claim adjustments, as well as providing support and education to the staff as necessary.

ESSENTIAL FUNCTIONS

1.Support Administrator in performing testing of transaction system programming of claim adjudication programming including but not limited to benefit thresholds and tracking, authorization rules, timely filing parameters, etc.,

2.Assist with testing of system modifications released by the data center to confirm accuracy and desired result of the requested programming before scheduling migration to the production environment.

3.Review and analyze a variety of claim samples including auto-adjudicated claims to assure pricing per contractual agreement, negotiated rate or to Medicaid and Medicare rates.

4.Review and analyze claim adjustments to identify root cause of incorrect claims processing and determine appropriate action to minimize future errors.

5.Identify and communicate trends observed in order to introduce and/or revise policies and procedures necessary to improve staff processes and performance as recommended.

6.Provide consistent feedback to staff in a timely manner both individually and collectively.

7.Support staff in answering questions pertaining to coding, edit resolution and policy application.

8.Maintain and compile individual, departmental and client quality data.

9.Assist with the maintenance of claims processing policies and procedures utilized in the training of staff.

10.Effectively communicate up-to-date information to all staff including management

EDUCATION AND EXPERIENCE

•High School diploma / GED required; college course work preferred.

•Minimum two (2) years’ experience as a medical Senior Claim Examiner, Call Center Advocate, Business Analyst or Trainer

•Knowledge of UB04 / CMS1500 claims, ICD-10 / Revenue / CPT / HCPCS diagnosis and procedure coding, claim adjudication processes, EDI and OCR claim submission, Medicare and Medicaid reimbursement methodologies including APR DRG / Exempt Units / APG / RBRVS / APC.

•Proven ability to effectively and efficiently analyze data and summarize in an organized and professional manner. 

REQUIRED SKILLS

•Excellent verbal, written and presentation skills required.

•Proficient in Microsoft Office (Word, Excel, PowerPoint, and Access) required.

•Ethical Conduct.

•Strategic-Critical Thinking.

•Leadership.

•Decision Making.

•Financial Management.

•Communications Proficiency.

•Presentation Skills.

EEO STATEMENT 

In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.