Simsy Ventures

Claims Specialist

• Analyze and process a variety of complex medical claims in accordance with program policies and procedures, ensuring accuracy and compliance.
• Adjudicate claims according to program guidelines, applying critical thinking skills to navigate complex scenarios.
• Ensure prompt claims processing to meet client standards and regulatory requirements.
• Identify and resolve any barriers using effective problem-solving strategies.
• Collaborate with internal departments to proactively resolve discrepancies and issues.
• Use analytical skills to identify root causes and implement solutions.
• Uphold confidentiality of patient records and company information in accordance with HIPAA regulations.
• Maintain thorough and accurate records of claims processed, denied, or requiring further investigation.
• Analyze and report trends in claim issues or irregularities to management.
• Assist Team Leads with reporting to contribute to continuous process improvements.
• Engage in audits and compliance reviews to ensure adherence to internal and external regulations.
• Critically evaluate and recommend process improvements when necessary.
• Mentor and train new claims processors as needed.

Medical Claims Processor I – Temporary Role

Medical Reviewer

• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Provide clear, well-documented rationales for service approvals or denials
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities to meet corporate and team objectives
• Provide guidance to LPN team members and support non-clinical staff through training and discussions
• Assist with special projects and additional responsibilities as assigned

RN – Medical Claims Reviewer

Analyst

• Review assigned TEFCA directory entries against authoritative corroboration sources, including NPPES, CMS Provider of Services data, IRS Tax-Exempt Organization Search, RCE/QTF published documentation, and QHIN-provided records.
• Apply the approved Task 2 Review Methodology and Control Framework to each assigned entry.
• Follow documented decision criteria to classify directory entries as:
• T1: Pass
• T2: Minor discrepancy
• T3: Inexplicable discrepancy
• T4: Non-compliant
• Research, validate, and reconcile healthcare directory data across multiple reference sources.
• Document review findings, evidence, discrepancies, and final dispositions in Jira with a complete audit trail.
• Ensure no entry is closed without a recorded disposition and supporting documentation.
• Escalate exception-path entries to the Lead Analyst for adjudication.
• Flag entries requiring QHIN outreach or additional review.
• Participate in Blind QA sampling and quality review activities as assigned.
• Maintain consistent review throughput to support weekly and biweekly reporting deadlines.
• Support a disciplined, accurate, and repeatable review process across high-volume data sets.

Medical Claims Processor I – Temporary Role

RN – Medical Claims Reviewer

Directory Review Analyst