Managed Care Claims Specialist / UMMS / Baltimore

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Job ID: 60579
Area of Interest: Clerical
Location: Baltimore, MD US
Hours of Work: 8:30 AM to 5:00 PM
Job Facility: University of Maryland Medical System
Employment Type: Full Time
Shift: DAY
What You Will Do:

The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women's and children's health and physical rehabilitation. UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you’ll enjoy as a member of our team. UMMS is currently seeking a Managed Care Claims Specialist for our Baltimore location.

1.  High School Diploma and two (2) years of experience with claims processing, billing systems and/or knowledge of HMO practices is REQUIRED.

2.  Certification as CHAA and/or CRCS or must be able to obtain or recertify within 1 year of employment is HIGHLY DESIRABLE.


Under direct supervision, organizes claim forms and adjudicates claim payments for facility and professional claims related to managed care global admissions and capitated contracts.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification.  They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1.  Organizes and logs facility and professional claims received by the managed care claims operations office.

2.  Monitors and maintains unbilled files. 

3.  Bundles charges, invoices payors, and adjudicates payments and makes referral decisions for facility and professional claims on the claims system. Adjusts claims to correct payment errors, i.e. provider refunds and overpayment notices. Monitors and resolves complex claim payment problems.

4.  Documents and maintains standard operating procedures for claims processing for managed care contracts and global contracts and assists with documenting and improving claims work flow process.

5.  Handles customer service communications received from providers and payors through telephone inquiries, FAX and letters and explains payment decisions.  Handles claim appeals.  Assists with claims system testing and verification of claims logic outcomes.

6.  Assists with the accounts payable process for claims and distributes and monitors claims disbursements to facilities and professional groups.    Posts payer receipts and prepares EOBs for payments to hospitals and physicians.

7.  Assists with problems that arise related to claim payments and check disbursements.

8.  Assists with UMMS and professional group aged trial balance (ATB) reconciliation.

9.  Provides training to Medical Center claims team members, as necessary.

10.  Attends meetings with employees of the managed care department, UMMS and UPI professional groups to provide information and to solve problems concerning claims processing procedures.  

***Employee Benefits*** 

As a University of Maryland Medical System (UMMS) employee, you will enjoy a comprehensive benefits program designed with you and your dependents in mind. Subject to any eligibility waiting period, all of the benefits are available to regular full-time employees and most benefits are available to regular part-time employees who are regularly scheduled to work twenty (20) or more hours per week. Many benefits are provided at no cost to employees. For others, the cost is shared between UMMS and employees.



What You Need to Be Successful:

High School Diploma or equivalent (GED) is required.  AA degree, or coursework in a related business field, is preferred.

Two years of experience with claims processing, billing systems and/or knowledge of HMO practices.


Knowledge, Skills and Abilities

Knowledge of medical terminology and health care coding including ICD-9, CPT, DRG, etc.  Knowledge of claims processing, managed care contract and coordination of benefits concepts.

Ability to work as part of a team and to set goals, prioritize work and coordinate execution of the work.

Demonstrated ability in the use of personal computers and related software, such as Microsoft Windows, Word, and Excel.  Experience with PowerPoint and Access is desirable.  Familiarity with IDX-BAR, MCA Checkwriter, and HBOC Star System is preferred.

Demonstrated ability to perform basic mathematical calculations, including; addition, subtraction, multiplication, division, and percentages using a calculator or related equipment.

Demonstrated proactive problem-solving skills.  Ability to interpret data and related information, and discern trends and tendencies, as well as determine the appropriate courses of action.

Highly effective verbal communication skills, including courtesy, resourcefulness and efficiency in answering questions, requesting  information, providing information, and explaining billing and collections policies and procedures are required.  Effective business writing skills are required for drafting memos and letters to other UMMS departments, patients and third party payers.
We are an Equal Opportunity/Affirmative Action employer.  All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law. 
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