Somerville, MA 02143
A prominent health care facilitator in Cambridge, Massachusetts is currently searching for a summer intern to aid in the claims process of authorization of payment for certain health care plans. This involves coordinating certain aspects of the claims process with third party administrators for health care plans.
Responsibilities for Summer Intern:
Help the claims process from authorization to payment in coordination with the plan’ s third party administrator (TPA). This includes but is not limited to:
- Monitor and process claims authorizations for staff and suggest improvements to workflows.
- Review/approve/process weekly claims invoice & payment detail reports, as well as monthly invoices for private pay and spend-down plan participants.
- Monitor, research, and resolve pended claims, identify patterns for resubmitted & adjusted claims
- Monitor and resolve claim pre-authorizations to facilitate accurate IBNR reporting
- Review and approve subset of invoices prior to submission to TPA
- Answer vendor calls/questions not initially resolved by TPA and refer to appropriate staff for resolution
- Research and resolve provider appeals
- Keep abreast of Medicare & Medicaid fee schedule changes and verify TPA has correct rates.
- Oversee the participant coordination of benefits (COB) list and ensure accurate claims payments for COB patients. Coordinate between health plans to resubmit claims when needed.
- Send enrollment/disenrollment files to TPA & pharmacy benefit manager (PBM).
- Process Medicaid/MassHealth reviews & Masshealth long term care conversions and ensure plan follows the regulatory process. This includes working with participants, and/or their families, the clinical team, MassHealth, etc.
- Monitor and resolve plan participant loss of Medicaid benefit
- Work closely with manager to reconcile Medicaid payments and act as the liaison to the State Administrating Agency to reconcile payments.
- Download variety of online files such as: MMIS, TPA reports, MMR, etc.
- Research rejected prescription drug events (PDE), review Medicaid only PBM report.
- Process non-staffing purchases.
Requirements for Summer Intern:
- Strong interpersonal skills with a customer service focus
- Technology savvy with a strong knowledge working with Microsoft Office
- Strong organizational skills with great attention to detail
- Strong multi-tasking and prioritizing skills with the ability to meet deadlines
- Excellent written and verbal communication skills
- Ability to work independently and as part of a team
- Must be eligible to work in the U.S. without sponsorship