MSP Specialist

The MSP Specialist is responsible for analyzing, researching and resolving CMS Section 111 MSP Response File errors to ensure data exchange compliance. Responsible for determining Medicare order of payment and loading the appropriate Medicare COB record. Must be able to research and determine if 411 reporting to the MSPRC and the CMS COBC is required. Must be able to review, process and track the Small Employer Exception (SEE) approvals from CMS. Responsible for initiating procedures to recover funds from providers, subscribers or beneficiaries where overpayments have occurred. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS
• Necessary Contacts: In order to effectively fulfill this position, the MSP Specialist must be in contact with:
  
  Various internal departments and staff including, but not limited to, Provider Services, Legal, Audit, IT, Benefits Operations Management and staff, Administrative Services and District Offices.
  
  Various external entities including, but not limited to CMS, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, other Plans, Medicare, Medicare MSP Contractors, U.S. Department of the Treasury, and Collection Agencies.

• High School Diploma or equivalent is required.

• 3 years of claims experience is required and
• 1 year of COB, refund or adjustment experience is required
• Medicare experience is preferred

• Must have expert knowledge in primacy determination, CMS Regulations, COB Rules and Regulations is required
• Knowledge of enrollment process is preferred
• Must demonstrate PC skills including Microsoft Office (e.g., Word, Excel, Outlook, etc.) and related software as well as other corporate software programs and applications.
• Must demonstrate verbal and communication skills with the ability to interpret and communicate information with tact, diplomacy, patience and professionalism.
• Must be able to assist both internal and external customers in a variety of situations as well as handle multiple tasks concurrently.
• Must be detailed oriented and organized.
• Able to shift priorities as needed to cover multiple tasks in the process as directed by leadership.

• None Required

• Researches, reviews, and sends appropriate documentation to Medicare/CMS, the Department of the U.S. Treasury and/or the collection agencies assigned to recoup overpayments on MSP cases.
• Responsible for meeting all CMS imposed deadlines to ensure compliance, avoid referral to the Department of Treasury, and added interest charges from CMS.
• Reviews, processes and tracks the Small Group Exception (SEE) approvals from CMS to ensure accuracy of enrollment and claims data.
• Receives or initiates an MSP 411 investigation from tasks, MSP file, customer service etc.
• Determines if 411 reporting to the MSPRC and CMS COBC are required.
• Creates MSP 411 reporting letters, if applicable, when Medicare has determined primacy incorrectly and send to the MSPRC and COBC. Failure to report discrepancy could result in a daily fine up to $1,000.00
• Maintains a tracking log of all MSP 411 reported situations.
• Determines if Medicare mistakenly made a Primary payment.
• Researches, determines Medicare order of payment (complex research including group size, employment status, ESRD and coordinating internally with Enrollment and Billing and other areas as well as with the CMS, COBC).
• Loads appropriate Medicare COB record to ensure accuracy of claims processing ensuring customer satisfaction.
• Reviews the group threshold report weekly and identifies group size changes that could trigger a change in the Medicare order of payment.
• Researches and makes necessary COB adjustments on claims received in MSP demand or 411 cases.
• Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify reject codes, edits, and processing codes pertaining to all claims that involve our coordination with Medicare in order to process the coordinated claims correctly.
• Reviews quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.
• Initiates procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred to ensure accuracy of claims processing and financial stability.
• Initiates oral and written communications with all internal departments as well as required external parties daily to complete adjustment processes and ensure a high degree of customer satisfaction.
• Analyzes and corrects MSP response file errors to ensure accurate reporting to CMS as mandated under Section 111 Mandatory MSP reporting.
• Maintains and records number of adjustments processed, and hours worked daily, in order to retain historical data needed to continually refine and define MSP Specialist position as needed to ensure high customer satisfaction.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.