tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.
POSITION SUMMARY
The Claims Analyst is responsible for processing complex healthcare claims in accordance with internal policies, provider contracts, and applicable regulations. This role requires analytical expertise, thorough knowledge of reimbursement procedures, and a collaborative approach to resolving claim issues and supporting provider education efforts.
PURPOSE
The Claims Analyst is accountable for and oversees the following tasks:
- Reviews, processes and verification of insurance claims to ensure compliance with policy terms and regulatory requirements.
- Confirm reimbursement accuracy upon claims processing per the Provider Contracts or SCA/LOA agreements on file when processing claims.
- Ability to analyze claims EOP pend/denial codes and troubleshoot why claim did not pass business requirements.
- Collaborate with Customer Service Analysts to educate/re-educate a network of providers on clean claim requirements.
- Ability to meet Claims productivity standards (Quantity/Quality) consistently and self sufficiently.
- Support ad-hoc reporting needs including but not limited to: Auth/Claims Mismatch Files, Eligibility, Network requests for claims data etc.
- Ability to apply/retrain knowledge of coding in order to determine if claim should be denied or approved per claims policies.
- Review documentation, analyze submitted claims data with an average of 95% accuracy monthly.
- Escalate any system issues or roadblocks that prevent hitting claim metrics as applicable.
ESSENTIAL JOB FUNCTIONS AND DUTIES
- Processing claims within the Claims Policies at 95% accuracy and meeting productivity standards as outlined
- Thorough Knowledge of EOB denial/pend codes, HIPPS, HCPCS and DX codes in order to process claims within regulations.
- Escalating all Provider Claim issues and systemic errors to ensure positive rapport with our network Providers in accordance with PHCN/tango Claims Policies and Procedures
- Knowledge of Medicaid EVV verification process for accurate claims processing.
- Knowledge of PDGM reimbursement processing for Medicare claims.
- Knowledge of authorization process for accurate claims processing.
- Familiarity with EDI claims/ claims submission related to CMS requirements.
REQUIRED QUALIFICATIONS
- 3 ~ 5 years of direct experience minimum in Healthcare Insurance, Claims Adjudication and EDI requirements.
- In-depth knowledge of Medicare/Medicaid claims processing and CMS regulations.
- Detailed knowledge of claims adjudication - medical coding; HIPPS, CPT and HCPCS codes.
- 1-3 years in revenue cycle management.
- In-depth knowledge of eligibility, authorization process, skilled home health care procedures, and COB practices.
- Detailed knowledge of multiple benefit plan designs including In/Out of Network designs for DSNP, MA HMO, POS, PPO etc.
SKILLS AND ABILITIES
- Beginner level Microsoft Office skills (PowerPoint, Word, Outlook).
- Intermediate level Microsoft Excel skills.
- Analytical, research, problem solving, and decision-making skills.
- Ability to adjudicate 185+ claims a day.
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.
3-5 years healthcare insurance, claims adjudication, and EDI experience; in-depth Medicare/Medicaid and CMS knowledge; medical coding (HIPPS, CPT, HCPCS); 1-3 years revenue cycle management; Microsoft Office and Excel skills; ability to adjudicate 185+ claims daily.
Key Responsibilities
- processing claims
- verifying reimbursement
- educating providers
Skills & Tools
Microsoft Office, Microsoft PowerPoint, Microsoft Word, Microsoft Outlook, Microsoft Excel
Job Details
- Category: Healthcare Services - Allied Health
- Seniority: Mid Level
- Commitment: Full Time
- Workplace: Remote — United States
- Languages: English
About Tango
A leader in home health management providing innovative post-acute solutions and claims processing services. — Industry: Healthcare