MetroPlusHealth 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, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

This position is responsible for the data entry and system adjudication of BH claims. The incumbent authorizes final disposition of claims within prescribed guidelines in an accurate and timely manner.

• Process claims involving medical and/or surgical services; screens for complete member/provider information
• Applies administrative policies when necessary, utilizing the claims processing manuals
• Authorizes the generation of letters/questionnaires to providers to obtain additional information
• Reviews descriptions of services on claims to determine validity of charges of the presence of errors
• Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies
• Maintains production and quality goals established for the department
• Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars

• Associates Degree or any combination of education/experience
• Minimum 2 years’ experience in the healthcare insurance industry with knowledge of integrated claims processing
• Proficient Data Entry Skills
• Through knowledge of medical terminology, CPT, ICD-p, and Revenue Codes

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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