Claims Research Specialist

Claims Research Specialist

The Claims Research Specialist will oversee and manage research efforts related to claims overpayments, underpayments, and billing issues within a managed care service organization. This role involves review / ensuring accurate and timely resolution of discrepancies, and working collaboratively with providers and internal departments to enhance claims processes and improve financial outcomes.

Essential Functions :

• Research and identify root cause resulting in claim processing discrepancies for all claim types
• Perform an analysis of the claims processing by reviewing contract, system configuration, benefits, financial risk (DOFRs), and manual adjudication to identify the cause of the erroneous claim payment
• Responsible to ask clarifying questions from our internal supporting departments or external providers when information is incomplete or inaccurate to ensure thorough and accurate research
• Responsible for communicating via inquiry form, email and telecommunication across multiple areas of the organization to ensure customer resolution is complete
• Lead investigations into claims overpayments, underpayments, and billing issues, ensuring accurate identification and resolution of discrepancies.
• Analyze complex claims data to identify trends, root causes, and opportunities for process improvement.
• Ensure thorough documentation of all research activities and findings, maintaining accurate records for audit purposes.
• Collaborate with internal departments, including claims processing, UM, compliance, and provider relations, to develop and implement strategies to prevent future claims issues.
• Participate in the development and enhancement of claims processing systems and tools.
• Recommend policy and procedure changes based on research findings to improve efficiency and accuracy in claims processing.
• Serve as the primary point of contact for the providers and / or provider relations team regarding claims research issues, facilitating effective communication and resolution of disputes.
• Educate providers on claims submission guidelines and billing practices to reduce the occurrence of errors.
• Build and maintain strong working relationships with provider representatives.
• Prepare and present detailed reports on claims research activities, findings, and outcomes to senior management.
• Ensure compliance with all relevant federal, state, and local regulations, as well as organizational policies and procedures.
• Monitor and respond to regulatory changes that impact claims processing and research activities.
• Schedule and lead meetings with all affected areas to provide status updates of next steps, expected completion dates, and resolution of the issues.
• Maintain and monitor a comprehensive dashboard of the current open and resolved claim issues.

Qualifications :

Minimum Qualifications :

Bachelors degree in Business, Healthcare Administration, or a related field or experience in lieu of.

Minimum of 5 years of experience in claims research, analysis, or a related role within a managed care or healthcare environment.

Proven experience in a lead role, with strong project team management skills.

Advanced knowledge of healthcare claims processing, coding (ICD-10, CPT, HCPCS), and billing practices.

Proficiency in using a managed care and / or claims processing platform.

Preferred Qualifications :

Experience with data analytics tools and software such as SQL, SAS.

Previous experience working directly with healthcare providers or within a provider network setting.

Masters in Business, Healthcare Administration, or related field.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.