Portfolio analyst Jobs in Pompano Beach, FL

Job Description

Job Description

P OSITION S UMMARY :

This position is responsible for performing pre-payment audits and ensuring timely and accurate claim payments utilizing analytic reporting and coding software tools.

E SSENTIAL D UTIES AND R ESPONSIBILITIES :

• Facilitates pre-payment audit reporting and payment posting process to ensure accuracy of payments being made to providers and facilities.
• Review and process claim audit coding reports on a daily basis to ensure appropriate edits are applied in order to achieve the maximum financial outcomes.
• Creates claim adjustments, retro adjudications due to rate changes, and reprocessing projects identified during the internal audit process.
• Request and post claim payment refunds and recoup overpayments as necessary.
• Reviews all identified over / under payments to determine whether claims payment discrepancies are due to system configuration, training issues or erroneous claims processing.
• Responsible for testing of benefit design, contracts, and all claims related system updates and upgrades.
• Responds to claims questions from all departments and assists with problems encountered on a daily basis.
• Responsible for first level claim appeals processing in accordance with contractual requirements.
• Applies accurate principles, policies, procedures and regulations, including : benefit interpretation, Coordination of Benefits (COB), deductibles, co-insurance and out of pocket maximums to the adjudication process.
• Regularly trains, assigns, coordinates, and reviews the work of staff.
• Advise Claims Management of any problems or inaccuracies as a result of daily operations.
• Processes claim corrections and COB updates via interdepartmental CRM process.
• Assists with projects and internal or external audits as needed.
• Identifies inappropriate or questionable claims and refers to Claims Leadership for review.
• Keep current on all plan benefits, contracts, and claims system upgrades.
• Processes professional claims, facility claims, ad hoc vendor payments and member reimbursement requests as needed.
• Update and create internal Standard Operating Procedures and provide related training to team members.
• Responsible for identifying efficiencies and recommending process improvements to increase auto-adjudication rates and reduce manual processes.
• Maintains courteous, helpful and professional behavior on the job and displays a willingness and ability to be responsive in a warm and caring manner to all customer groups.

Q UALIFICATIONS :

S KILLS AND A BILITIES :

Work Schedule :

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

P HYSICAL D EMANDS :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and / or move up to 15 pounds.

W ORK E NVIRONMENT :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work

inside / outside the office, travel to other offices, as well as domestic, travel. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.