Description

Employee’s Name: TBD Job Title: CFTSS and HCBS Claims Analyst

Supervisor: Director of CFTSS and HCBS Start Date: TBD

Department: CFTSS and HCBS FLSA Status: Full Time – Exempt

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GENERAL DESCRIPTION:

The CFTSS and HCBS Claims Analyst coordinates with the CFTSS and HCBS Payroll Clerk, Finance Director, and Managed Care Director to ensure all CFTSS and HCBS services are billed and adjudicated in accordance with New York State Department of Health (NYSDOH) and federal regulations. The CFTSS and HCBS Claims Analyst can work independently and efficiently under pressure. The CFTSS and HCBS Claims Analyst conducts follow-up correspondence to resolve open and/or denied claims. The CFTSS and HCBS Claims Analyst is a liaison between MDPYFS and the MMCPs (Medicaid Managed Care Plans) that insure the clients in our CFTSS and HCBS Program.

MAJOR DUTIES AND RESPONSIBILITIES:

• Verify client’s eligibility weekly in ePACES.
• Research and resolve complex eligibility discrepancies with the health insurance carriers(s).
• Initiate and complete prior authorization requests before the rendering of services.
• Complete the prior authorization reconsideration request(s) as necessary.
• Maintain updated billing profiles for all clients in the clearinghouse database.
• Maintain NYSDOH CFTSS and HCBS compliance.
• Audit service provider utilization for accuracy and continuity of care in compliance with CFTSS and HCBS guidelines.
• Report service provision overutilization including but not limited to fraud, waste, and/or abuse.
• Process, correct, and/or rebill claims for adjudication using ICD-11 codes.
• Audit Explanations of Payments (EOP) from all health insurance carriers for accuracy.
• Apply medical knowledge to the research and resolution of complicated claims.
• Reconcile payroll spreadsheets with clearinghouse and Medicaid invoices, resolving discrepancies.
• Recoup claims revenue via the dispute, appeal, and/or grievance process.
• Troubleshoot and resolve clearinghouse reports.
• Liaise between NYS Medicaid programs, health insurance carriers, referring agencies, and licensed medical providers.
• Ensure documentation and service provision meet standard requirements for New York State’s Medicaid program, OCFS-CFTSS and HCBS, and MMCP.
• Ensure ongoing communication with the CFTSS and HCBS Director, Managed Care Director, CFTSS and HCBS Supervisors, Service Providers, and Care Managers (internal and external) regarding escalation of service-impacting issues.
• Evaluate and analyze cross-functional department workflows.
• Develop and implement process improvement initiatives.
• Perform ongoing independent research related to changes in industry standards.
• Attend team meetings in support of the CFTSS and HCBS Department providing necessary feedback.
• Perform all other duties as assigned.

Requirements

 QUALIFICATIONS:

EDUCATION:

Bachelor’s Degree

EXPERIENCE:

At least two (2) years of administrative or supervisory experience

At least two (2) years of medical billing experience

Familiarity with billing and coding terminology

REQUIRED SKILLS AND ABILITIES:

Highly organized and detail-oriented

Business Acumen

Effective oral and written communication skills

Consultation 

Relationship management

Time management

Data input

Ability to communicate effectively with stakeholders 

Understanding and incorporation of the Lasallian Culture of Care as a work philosophy

Ability to work varying hours as needed

Proficient computer skills (Microsoft Word & Excel)

Excellent problem-solving capability and ability to meet multiple deadlines under pressure

ACTIVE CERTIFICATIONS:

Mandated Reporter

Lasallian Culture of Care (LCC)

Required training as delineated by the oversight agency and or MDPYFS

SUPERVISORY RESPONSIBILITY:

This position may serve as a consultant and mentor in the agency.

EXPECTED HOURS OF WORK:

The number of days will vary based on the agreed work schedule. The hours of work are up to forty (40) hours per week. This position may require long hours and occasional weekend work as the job demands.

BACKGROUND VERIFICATION and CLEARANCE:

Section 424-A of the New York Social Services Law requires an authorized agency to inquire whether a candidate for employment with child-caring responsibilities has been the subject of a child abuse and maltreatment report.

Credential Verification

Medical and Physical clearance, which includes TB screening

State Central Registry (SCR) Clearance

Staff Exclusion List (SEL)

Justice Center Background Check

Required training as delineated by the oversight agency and or MDPYFS

Reference Verification

PHYSICAL REQUIREMENT:

Lifting requirement of 50 Lbs.

Ability to meet physical requirements of the position when performing the following: standing, walking, sitting, bending, stooping, squatting, kneeling, and climbing.

SALARY: $60,000 - $70,000