Job Description:

Join our employer team and make a difference! At employer, we are committed to serving, healing, leading, educating, and innovating. We believe that our dedicated employees are the reason for our success. Every award earned, every record broken, and every patient helped is a result of our employees' hard work and dedication.

As an employer employee, you will have the opportunity to make a difference and contribute to our mission. Discover your future today by joining employer Health!

Job Summary:

This position is responsible for the day-to-day delivery of claims functions to ensure compliance with state and federal regulations for the employer Health Plan.

Education:
- High school diploma or equivalent required.
- Bachelor's degree in business or healthcare administration preferred.

Work Experience:
- 3 years of medical claims adjudication experience required.
- 6 years of medical claims adjudication experience preferred, preferably in a government programs setting such as Medicare or Medicaid.
- 1 or more years of experience working in Facets claim system and/or QNxt preferred.

Knowledge, Skills, and Abilities (KSAs):
- Certified Professional Coder preferred.
- Knowledge of state and federal claims regulations.
- Customer service skills and ability to support positive outcomes for internal and external customers.
- Proficiency in using computers, software, and web-based applications.
- Analytical/research skills and ability to anticipate and mitigate issues.
- Effective verbal and written communication skills.
- Strong interpersonal skills and ability to work in a team environment.
- Time management and organizational skills.

Job Duties:
- Investigate and research claims in conjunction with employer Health Plan's primary claims processing vendor.
- Review and evaluate benefits coverage and/or liability.
- Secure and analyze necessary information.
- Provide technical advice to primary claims processing vendor and internal business operational partners.
- Ensure claims payments are consistently adjudicated in a timely and accurate manner.
- Lead the high-dollar claims review process.
- Participate in federal and state audits as needed.
- Participate in the delegation oversight process for claims.
- Engage to ensure maximum out of pocket (MOOP) indicators are applied appropriately.
- Perform other related duties as assigned.

Additional Information:
- This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities.
- The employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct.
- The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.
- Physical and Environmental Demands: Sedentary Work. Normal routine involves no exposure to blood, body fluid or tissue. The incumbent has no occupational risk for exposure to communicable diseases. There may be occupational risk for exposure to hazardous medications or hazardous waste within the environment.
- Individuals who reside in and will work from the state of Colorado are not eligible for remote work positions.
- Ochsner Health endeavors to make our site accessible to all users. If you need an accommodation to complete the application process, please contact our HR Employee Solution Center. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.