JOB SUMMARY
Responsible for the accurate and timely review of complex claims in accordance with applicable contracts, state and federal regulations, health plan requirements, policies and procedures, and generally accepted business practices.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Analyzes professional and hospital claims for accuracy according to set dollar thresholds and meets and maintains production and quality standards.
- Reviews authorization and/or provider's contract and adjudicates claims accordingly.
- Perform any correspondence, follow-up and any projects delegated by claims supervisor.
- Provide assistance to the customer service department with escalated member issues.
KNOWLEDGE, SKILLS, ABILITIES
- General office equipment experience (i.e. photocopier, fax, calculator, ability to operate a PC and previous exposure to the Microsoft Windows environment).
- Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims.
- Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology.
EDUCATION / EXPERIENCE
- High School Diploma or Equivalent preferred
- 2-3 years claims experience in a managed care environment preferred.
- 3-5 years claims processing UB-04 and professional experience preferred
- 3-5 years Medicare, Medicaid, Medical, Commercial, PPO and/or HMO claims experience preferred.
PHYSICAL DEMANDS
- Must be able to work in sitting position, use computer and answer telephone
- Ability to travel
- Light physical effort (lift up to 10lbs).Regularly needs to be able to bend, stoop and reach to file.
