Lead Medicaid Claims Review Specialist

Location: Miami, FL
Analytica is seeking a Lead Medicaid Claims Review Specialist to be responsible for initiating, supporting, monitoring and evaluating data processing review activities related to compliance with contract deliverables, internal and external performance requirements, and continual improvement. This position is responsible for providing support to the Data Processing Review Management staff and Operations area. This position will be responsible for auditing Medicaid FFS, Medicaid CHIP and managed care claims. The work will be performed remote and at the Medicaid state locations. Expecting 50-70% travel. Onsite work will be scheduled for two weeks at a time. Will need to fly out on Sunday and be prepared to work through noon on Friday.

Primary Responsibilities Include (But Are Not Necessarily Limited To):
  • Extensive travel (air/car) – 60-75% per year - with your team to scheduled states for Data Processing reviews. Travel will generally be Sunday through Thursday and/or Friday based on workload. 
  • Develop performance standards and output standards for less experienced staff to meet CMS metrics/timeliness requirements.
  • Collaboratively work with Medicaid staff to set goals, develop processes, and set timelines
  • Independently works with state IT staff to gain access and troubleshoot problems that prevent access to state MMIS for direct reports. 
  • Work one-to-one with less experienced reviewers to develop individualized standards involving claims processing, authorization, and payment; reviews individual outcomes against these standards; and collaboratively develops an individualized corrective plan if there are significant discrepancies with these standards. 
  • Support experienced team members with review of exceptions and resolution of conflicting findings from lower level reviewers.
  • Research complex review situations and arrive at an accurate conclusion.
  • Review and analyze multiple claim processing, eligibility enrollment, and provider enrollment systems. Make an informed decision to determine if the information in all systems resulted in an accurate payment determination.
  • Consult with management and staff stakeholders the implication of how state and federal policies and regulations are applied in differing claims scenarios.
  • Read, interpret, and apply complex federal and state regulations and their impact to claim processing. Suggest revisions to any impacted work products or standard operating procedures as a result of changes in federal or state regulations impacting Medicaid claims payment accuracy.
  • Must be able to audit all phases of a claim and determine if all phases were processed accurately.
  • Independently review claims to determine appropriateness of payment using state and federal policy. Among criteria to be reviewed includes, but is not limited to; beneficiary information, third-party liability, beneficiary liability, provider risk based screening, accurate claim payment, and duplicate claim submission.
  • Correctly apply state policies, statutes, and regulations to the review criteria on each claim in the sample for all review criteria. 
  • Review claims remotely to determine appropriateness of payment using state and federal policy - review bene info, review TPL, review provider info, review for correct payment, review for duplicates.
  • Correctly apply federal statutes and regulations to the review criteria on each claim in the sample for all review criteria.
  • Accurately and efficiently document all findings in SMERF for all levels of reviews.
  • Independently conduct periodic Claims Processing reviews to insure timely and accurate processing.  Recommends corrective action to management & staff.
  • Investigates Claim Payment Systems and analyzes data to determine if systemic errors are occurring. Reports discrepancies and suggests corrective action to management to resolve the discrepancies.
  • Using review experience, determine what type of reports to build within the case management system to demonstrate both positive and negative trends in errors cited during reviews. Using these reports analyze the trends and determine potential causes for the increase or decrease in citations. Critically evaluate the trend and present theories to the management team, stakeholders, and customers to reverse negative trends and promote positive trends.
  • Prepare reports as needed for both internal and external customers.

  • ​Extensive knowledge of medical terminology and coding principles.
  • Ability to read insurance claims, both paper and electronic, and a basic knowledge of insurance claims systems
  • Knowledge of, and the ability to correctly identify, insurance coverage guidelines
  • Familiarity with CPT codes, ICD-10-CM codes, and HCPCS codes
  • Knowledge of and ability to use Microsoft Word, Excel and Internet applications.
  • Strong critical thinking and decision making capability.
  • Familiarity with computer systems in general, including accessing FTP websites and DOS systems.
  • Preference for Bilingual (Spanish) - Fluency in speaking, reading and understanding the Spanish language.
  • Ability to quickly adapt and thrive in a changing work environment
  • Minimum three (3) years of management experience. 
  • At least four (4) years’ experience in medical terminology and insurance claims payment systems.
  • At least four (4) years of Medicaid/CHIP experience
  • Must have and maintain a valid driver's license for the associate’s state of residence.
  • Must live within reasonable commuting distance of a major airport.
  • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program

About ANALYTICA: Analytica is a leading consulting and information technology solutions provider to public sector organizations supporting health, civilian, and national security missions. Founded in 2009 and headquartered in Washington D.C., the company is an established SBA certified HUBZone and 8(a) small business that has been recognized by Inc. Magazine each of the past three years as one of the 250 fastest-growing companies in the U.S.  Analytica specializes in providing software and systems engineering, information management, analytics & visualization, agile project management, and management consulting services. The company is appraised by the Software Engineering Institute (SEI) at CMMI® Maturity Level 3 and is an ISO 9001:2008 certified provider.
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