Claims Adjustment Specialist I

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 40 years, MetroPlus Health has been committed to building strong relationships with its members and providers.

Position Overview

As a Claims Adjustment Specialist I, this individual will be responsible for analyzing standard to complex post-paid healthcare claims that require in depth research to determine accuracy and mitigate payment errors. The Claims Adjustment Specialist I will also be responsible for adjusting medical claims that

result in overpayment or underpayment due to claim processing system issues, contract amendments, processing errors, or other issues. This position will be responsible for responding to inquiries from providers whose claims may be paid incorrectly and performing accurate data entry and maintenance accurate records and files.

Work Shifts

9 : 00 A.M 5 : 00 P.M

Duties & Responsibilities

• Research and analyze medical claims adjustment requests along with related documentation to determine payment accuracy and adjust / adjudicate as needed using multiple systems and platforms.
• Ensure that the proper payment guidelines are applied to each claim by using the appropriate tools, processes, and procedures (e.g., claims processing P&Ps, grievance procedures, state mandates, CMS / Medicare / Medicaid guidelines, benefit plans, etc.)
• Research claims that may have paid incorrectly and communicate findings for adjustment; Adjust claims based on findings (i.e., correct coding, rates of reimbursement, authorizations,

contracted amounts etc.) ensuring that all relevant information is considered.

Minimum Qualifications

Professional Competencies

Benefits

NYC Health and Hospitals offers a competitive benefits package that includes :

#LI-Hybrid

#MHP50