A class incumbent performs specialized social services work for the Division of Economic Services with responsibility for evaluating, adjudicating, and reviewing pending and paid medical claims for Medicaid, to determine compliance to Medical Third Party Liability program policies and third party liability resources.
Nature and Scope
An incumbent reports to an administrative supervisor and is responsible for identifying, initiating and developing third party reimbursement cases on an individual case by case basis. Work includes evaluating and implementing established procedures to recover program funds where third party resources have been determined. An employee in this class assists in developing and implementing measures to identify and verify third party resources, recovers program funds, and processes daily pending medicaid claims for third party coverage. In addition, an incumbent works with insurance companies, recipients, fiscal agents, providers, department and division personnel and other appropriate contacts to correct billing problems, interpret policy and track and monitor parties responsible for outstanding claims and recovery. The incumbent also conducts annual post payment reviews of recipient claims histories, effects recoveries and periodic review and resolution of aged and pending cost-avoidance claims. A significant aspect of the work involves developing measures to identify and verify third party resources for cost-avoidance and recovery functions for shared use with DHSS DCIS/PACT system and maintaining up to date resource data on State and fiscal agent eligibility systems.
Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, incumbents can complete job duties of similar kind not specifically listed here.
Reviews claims of Medicaid recipients to establish and collect Third Party Liability reimbursement.
Implements established procedures to recover program funds where Third Party Liability sources have been determined.
Investigates and monitors processing system of recovery in compliance with Medicaid Third Party Liability policy, assignment and subrogation laws, statutes of limitations and various claims processing systems.
Conducts post-payment reviews of paid claims through interpretation of histories and accomplishes recoveries of major medical expenditures.
Establishes measures to identify and verify third party resources to support cost-avoidance, recovery of funds and implementation into the DHSS DCIS/Pact institutional billing system.
Maintains accurate up-to-date third party liability files and data on eligible medicaid recipients for entry into computerized system.
Knowledge, Skills and Abilities
The intent of the listed knowledge, skills and abilities is to give a general indication of the core requirements for all positions in the class series; therefore, the KSA’s listed are not exhaustive or necessarily inclusive of the requirements of every position in the class.
Knowledge of Medicaid program, third party policy, fiscal agent claims processing system, cost-avoidance functions, federal/state laws, insurance resources, and benefit payment criteria.
Knowledge of medical terminology, insurance company claims processing systems and application of policy benefits.
Knowledge of third party recovery systems and procedures, cost avoidance policy procedures, community resources, Division of Economic Services intake processes, statewide employer and insurance company medical plans.
Knowledge of Medicaid coordination of benefits codes, system plan codes and data entry documents.
Knowledge of validation procedure, tracking methodology, third party accounts receivable procedures, claims tracking network and fiscal agent generated computer reports.
Skill in critical analysis, application and utilization of third guideline and resources as analytical tools.
Skill in interpersonal, oral and written communication techniques.
Ability to interpret claims, insurance policies and benefits and apply third party procedures to resolve problems of varying difficulty.
Ability to apply established recovery strategies and make fiscal related decisions.
Ability to gather, verify and assimilate data.
Ability to communicate policy and guidelines to others and unusual and complex problems.
JOB REQUIREMENTS for Medicaid Third Party Liability Analyst Applicants must have education, training and/or experience demonstrating competence in each of the following areas:
Six months experience in benefits claims processing such as health, dental, or life.
Six months experience in interpreting laws, rules, regulations, standards, policies, and procedures.
Six months experience in using an automated information system to enter, update, modify, delete, retrieve/inquire and report on data.
Six months experience in narrative report writing.
Knowledge of health care reimbursement which includes reviewing and categorizing claims for proper billing, analyzing cost reports, examining cost containment, and interpreting and analyzing laws, rules, regulations, policies, procedures and standards affecting reimbursement and recovery.