o project development and various stages of system testing, Unit, Product (System), Integrations, Regression, and User Acceptance Testing
o Investigation and problem solving
o Claims Adjustments, Audit, Editing, Projects and Initiatives, Reporting, Coordination of Benefits, Encounters and Production
o Resolve CMS Grievance and Adjustment appeals and resolution process, including claims CMS CTM complaints.
o Claims processing & recovery
o CDAG&ODAG CMS claims auditing and departmental monitoring
o Claims adjustments & retro recovery
o Coordination of Benefits (COB), including State, Federal and Third Party Liabilities and COB regulations and guidelines
o Quality Assurance (QA) internal auditing o Microsoft Office application, (i.e. Access, PowerPoint, Excel, Visio & Microsoft word.)
o Facets software application, IKA gateway, Pega application and other system.
o ESRD MSP eligibility requirements
o Enrollment OHI eligibility validation.
o Enrollment reporting (MMSEA- SECT 111 Mandatory Reporting & COBA-CMS (Crossover claims) Reporting
o ECRS submission (Flat File Creation & Web Flat File Submission)
o Claims processing and COB claims processing
o Claims audit, appeal and adjustment
o MSP & Coordination of Benefits rules and guidelines
o MSP Premium Adjustment process and recovery
o Proficienct in CMS compliance and regulatory in Claims, Enrollment and COB MSP Part C and Part D
o Medicare Advantage and/or Medicare Prescription Drug Plans (MAPD/PDP) requirements
o MA/MAPD/PDP Medicare claims recovery (Medical & Pharmacy)
o Proficient in all claims processing, MSP processing and claims appeal & grievances.
o Manage Claims and MSP CMS Plan Organization and Financial Audits.
o Initiate and manage cross-functional teams and multi-disciplinary projects
o CMS guidelines, Federal Regulations, CMS Audits guidelines, CMS Enrollment, MSP & Claims Manual requirements and CMS chapters (MSP/Claims Processing/CMS Compliance)
o NCQA and HCFA guidelines Electronic Correspondence Referral System (ECRS) submission
o design staff work processes, policies and procedures
o staff training and supervision o project planning management and delegate tasks
o team improvements and staff development
o Strong critical thinking, decision making and problem solving skills
o manage day to day department operations
o coaching, counseling and evaluation of employee's performance
o maintains and promotes organizational values
o solving, investigation and critical thinking
o establish and maintain positive and effective work environments
o maintain and support required department production for quality, quantity and completion of work
o Review and advise claims complexity and sensitivity issue
o Recommend and assist FDR acquisition of vendors and other tools or equipment, for optimize departmental resources and performance and output
Subject Matter Expert Government MSP, COB , CMS MSP Government
Enrollment, Dual Eligibility & Claims process
Claims Processing & Appeal
Claims adjustment and recovery (COB)
Obtains information necessary to properly investigate and evaluate each case by corresponding with agents, insureds, claimants, witnesses and others
Monitors appropriate claim outcomes through self-audit process
May serve as a member of project teams, contributing to the achievement of project objectives.
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