Salary Range:$57,900.00 To $72,400.00 Annually
UNITE HERE HEALTH serves 190,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!
The Cost Containment Specialist acts as a liaison between the Claims Department and our networks and vendors. Their role is to ensure that all necessary information is received and reviewed within the specified timeframes for claims that meet the defined criteria. This position reviews medical records to ensure claims are billed appropriately and involves Medical Management as needed.
Additionally, the Cost Containment Specialist provides guidance on procedure and diagnosis coding for our claims processing system. They are also responsible for reviewing current claim categories to ensure the accuracy of procedure and diagnosis codes, and for providing updates when new codes are introduced.
ESSENTIAL JOB FUNCTIONS AND DUTIES
- Coordinates with the Claims Support team once medical records are received from the networks
- Requests medical records from networks if they are not received timely
- Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation related to benefit requirements, the accuracy of the claim filed, and the appropriateness or frequency of care rendered=
- Submits medical records and all pertinent information to Medical Management and/or Claim review vendors
- Tracks the status of all submitted cases to vendors to ensure timelines are met
- Follows up with vendors if claims are approaching the deadline
- Coordinates meetings with vendors and Medical Management as needed
- Adjudicates corrected claims according to the plan benefit designs
- Establishes and maintains relationships with key stakeholders to ensure the successful completion of high dollar claims under review.
- Offers suggestions on process improvement initiatives by identifying patterns and/or trends
- Generates and provides regular status reports of high-dollar claims, including trends, challenges, and outcomes to the Leadership team
- Assists with claims-related projects and process improvement initiatives
- Ensure the accuracy of various categories within the claims system (e.g., surgical categories)
- Monitor preventive care coding guidelines as defined in the Plan Documents (USPSTF, ACIP, and HRSA) for the Aurora-based plan units
- Review and advise the application of NCCI edits in our claims system and claims priced by our PPO vendors
- Review the accident code diagnosis list annually to ensure accuracy
- Review code categories related to defined pre-authorization lists
ESSENTIAL QUALIFICATIONS
- 4 ~ 6 years of related experience in a medical claim adjudication environment, or 3 years in a health care or insurance environment
- 3 ~ 5 years of medial coding experience
- Bachelor’s degree in Health Care Administration or related field or equivalent work experience required
- CPC Certification from AAPC or CCS-P Certification from AHIMA
- Working knowledge and experience interpreting benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
- Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
- Experience with medical terminology, International Classification of Diseases (ICD)10 and Current Procedures Terminology (CPT) codes
- Maintains an active coding certification
- Remains current on all coding guidelines
Salary range for this position: Salary $57,900 – $72,400. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.
Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week). This is a remote position.
We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).
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