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ProMedica Health System Adjustment Refund Adjudicator - Claims Adjustments - Full Time - Days in Maumee, Ohio

At Paramount, we offer insurance to both large and small groups and also cater to Medicare (Paramount Elite) subscribers in northwest Ohio and southeast Michigan. Our Medicaid product (Paramount Advantage) services those living in the state of Ohio. We maintain an accreditation by the NCQA – the National Committee for Quality Assurance – for our Ohio HMO, Elite and Advantage products. We’re also part of ProMedica, which is ranked the second most integrated health system in the U.S. and No. 1 in the Midwest. For more information about Paramount, please visit our website http://www.paramounthealthcare.com.

Basic Purpose

Review and process all provider refunds received by the Plan to ensure accurate and timely turnaround in accordance with Plan and governmental time frame standards. Supports claim investigation and adjustment processing for retroactively added and/or terminated members.

Primary Duties

  • Promptly investigate and process refund requests and/or returned provider checks to ensure timely follow-up and maximum recovery to the Plan in ≤30 days.

  • When necessary, compose clear and concise written correspondence to providers.

  • Promptly adjust claims to meet established Plan standards;

  • Production – 20 documents daily/expectation is to perform in a prompt and consistent manner, as this work has a high variability to volume and complexity in regards to investigation/reviews

  • Pended claims - no more than 2% over 30 days

  • Correctly adjudicate claims according to established department accuracy standards and support development of continuous quality improvement as an outcome of daily functions.

  • Payment 98%

  • Procedural 98%

  • Financial 98.5%

  • Analyze claim inquiries received through service forms and respond promptly, and/or route to appropriate area for review of the pended claim in ≤ 5 work days.

  • Respond to QA slip information within time frames set forth to ensure compliance of our quality initiatives.

  • Perform other duties as directed to support the overall operations of the Claims Department.

  • Demonstrates a thorough knowledge of the Plan's published claims processing procedures on the company’s intranet. Proficient with core applications of the current claims processing system and front-end imaging.

  • High School diploma

  • 3-5 years' experience in claims and/or adjustment processing required.

  • Previous experience with working in an accounts receivable/payable environment strongly preferred.

  • Software experience - Word and Excel required; Access preferred.

  • Demonstrated working knowledge of federal and state compliance and regulations; UB-04 and HCFA1500 encounter data. Group-specific guarantees strongly preferred.

  • Demonstrated excellent written, verbal, and interpersonal communications skills required.

  • Previous collections experience a plus.

  • Familiarity with provider billing and coding practices a plus.

  • Must be public relations-sensitive.

  • Demonstrated ability to handle detail and maintain confidentiality.

  • Ability to prioritize and handle large volumes of work.

  • Ability to work in a production environment that can be stressful.

  • Maintain a high level of motivation, initiative, and accountability.

  • Handle conflict in a productive manner.

  • The ability to move between workstations and use office equipment is required.

ProMedica is a mission-based, not-for-profit health and well-being organization headquartered in Toledo, Ohio. It serves communities in 28 states. The organization offers acute and ambulatory care, an insurance company with a dental plan, and post-acute and academic business lines. The organization has more than 49,000 employees, 12 hospitals, 2,500+ physicians and advanced practice providers with privileges, 1,000+ healthcare providers employed by ProMedica Physicians, a health plan, and 330+ assisted living facilities, skilled nursing and rehabilitation centers, memory care communities, and hospice and home health care agencies. Driven by its Mission to improve your health and well-being, ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. For more information about ProMedica, please visit www.promedica.org/aboutus.

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity or gender expression, age, disability, military or veteran status, height, weight, familial or marital status, or genetics.

Equal Opportunity Employer/Drug-Free Workplace

Requisition ID: 52695

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