Anthem Provider Reimburse Admin / Admin Sr (Job Family) - Any Anthem location or Remote - # PS12195 in Las Vegas, Nevada

Provider Reimburse Admin / Admin Sr (Job Family) - Any Anthem location or Remote - # PS12195

New

Location: Pennsylvania, United States

Field: Provider Network Management

Requisition #: PS12195

Post Date: 3 days ago

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care .

This is an exceptional opportunity to do innovative work that means more to you and those we serve atone of America's leading health benefits companies and a Fortune Top 50 Company.

Provider Reimburse Admin

Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.

Primary duties may include, but are not limited to:

  • Reviewing individual provider contracts together with Anthem and CMS guidelines to ensure compliant and accurate configuration of critical information systems.

  • Analyzing each new provider contract for coverage, policy, reimbursement development, and implications for system edits. (May also perform CPT/HCPCS code and fee schedule updates)

  • Responding to system inquiries and appeals-- primarily in order to troubleshoot claims adjudication issues related to configuration.

  • Conducting research of claims systems and system edits to identify issues and to audit claims adjudication for accuracy.

  • Performing pre-adjudication claims reviews (configuration testing) to ensure proper configuration was used.

  • Prepares correspondence to providers regarding coding and fee schedule updates.

  • Trains customer service staff on system issues.

  • Working with provider contracting staff when new/modified reimbursement contracts are needed.

  • Assisting with the analysis, documentation, configuration, and testing of current and future markets business requirements.

  • Supporting the upgrade of test environments.

Provider Reimburse Admin Sr.

Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. Serves as subject matter expert regarding reimbursement policies, edits, and coding conventions.

Primary duties may include, but are not limited to:

  • Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.

  • Works with other departments on claims adjudication workflow development and business process improvements.

  • May lead the full range of provider reimbursement activities for a state(s).

  • Leads projects related to provider reimbursement initiatives.

  • Serves as a mentor to less experienced administrators.

Provider Reimburse Admin

  • Requires a BA/BS degree; 2-3 years related experience; or any combination of education and experience, which would provide an equivalent background.

  • EOE.M/F/Disability/Veteran

Demonstrated knowledge and experience in the following areas is required for the role and must be included in the related or equivalent experience to meet the basic qualifications listed above:

  • Previous experience in care payer operations to include claims processing, claims auditing, claims testing and/ or claims research

  • Knowledge of one or more of the following claims paying systems: FACETS, AMISYS, NASCO, EZ-Cap, Rims, Ocare, Xcelys, NextGen, QNXT, ITS, IKA, WGS, Call Care Browser, GBAS, Genelco, HEALTHsuite, and Diamond

  • Direct experience in healthcare provider configuration and/or provider data management utilizing FACETS or one of the above listed systems

  • Must know how to read and analyze a contract (physician, ancillary and hospital)

  • Able to implement PCAs and load fee schedules

  • Able to use full range of Microsoft Office products proficiently

Preferred:

  • Medicare or Medicare/Medicaid experience

  • FACETS specific pricing configuration build experience

  • FACETS NetworX experience

  • Able to run Microsoft Access queries in relation to Facets

  • Knowledge of CPT/HCPCS coding

  • Certified coder

  • Experience working with the implementation of new business in a health insurance industry setting

Provider Reimburse Admin Sr.

Requires a BA/BS degree; 4-6 years related experience; or any combination of education and experience, which would provide an equivalent background.EOE.M/F/Disability/Veteran

Demonstrated knowledge and experience in the following areas is required for the role and must be included in the related or equivalent experience to meet the basic qualifications listed above:

  • Previous experience in care payer operations to include claims processing, claims auditing, claims testing and/ or claims research

  • Knowledge of one or more of the following claims paying systems: FACETS, AMISYS, NASCO, EZ-Cap, Rims, Ocare, Xcelys, NextGen, QNXT, ITS, IKA, WGS, Call Care Browser, GBAS, Genelco, HEALTHsuite, and Diamond

  • Direct experience in healthcare provider configuration and/or provider data management utilizing FACETS or one of the above listed systems

  • Must know how to read and analyze a contract (physician, ancillary and hospital)

  • Able to implement PCAs and load fee schedules

  • Able to use full range of Microsoft Office products proficiently

Preferred:

  • Medicare or Medicare/Medicaid experience

  • FACETS specific pricing configuration build experience

  • FACETS NetworX experience

  • Able to run Microsoft Access queries in relation to Facets

  • Knowledge of CPT/HCPCS coding

  • Certified coder

  • Experience working with the implementation of new business in a health insurance industry setting.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.