Certified Claims Processor I

AllCare Management Services•Grants Pass, OR

6d•Hybrid

About The Position

The Certified Claims Processor I is responsible for independently adjudicating professional claims in accordance with company policy, contract language, and applicable regulatory guidelines. This role applies coding knowledge and established claims processing standards to resolve standard and moderately complex claims while ensuring accuracy, compliance, and timely adjudication.

Requirements

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others.
Associate's degree (AA) from a two-year college or technical school in equivalent combination of education and experience is required.
Six months to one-year related experience and/or training in Knowledge of Medical Terminology, ICD-10CM, ICD10PCS, Current Procedural Terminology, Healthcare Common Procedure Coding Systems, CMS1500 and UB04 and other claim forms is required.
Current AAPC or AHIMA Certification Coding Certification Required (CPC, CPC-P)
Familiarity with the Healthcare industry.
Excellent organization and time-management skills.
Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
Knowledge of and compliance with HIPAA regulations.
Demonstrate accountability, inspiring trust and confidence from others.
Work with high initiative, energy and effectiveness in a fast-past environment.
Collaborate within a multidisciplinary, diverse team to provide professional service.
Interact positively with customers to satisfy needs and resolve problems in a pleasant and professional manner.
Prioritize and organize work according to competing timelines.
Allocate your time so that you can complete tasks within established deadlines.
Adapt to change, learn quickly, and work with ambiguity.
Maintain an attentive and empathetic demeanor.
Maintain a high degree of professionalism and confidentiality.
Take initiative and apply sound judgment in completing tasks and responsibilities.
Ability to read and comprehend simple instructions, short correspondence, and memos.
Ability to write simple correspondence.
Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs.
Has advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data.
Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.
Ability to work with problems involving a few concrete variables in standardized situations.
The employee must occasionally lift and/or move up to 10 pounds.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
The employee is occasionally required to stand; walk and reach with hands and arms.
The employee must be able to work onsite (for all scheduled shifts, occasionally, frequently, as needed).
The employee must be able to work from a home office (for all scheduled shifts, occasionally, frequently, as needed.)

Nice To Haves

EZ-Cap experience preferred.

Responsibilities

Independently adjudicates professional claims (CMS-1500) by applying benefits, pricing, coding guidelines, and contract terms.
Utilizes knowledge of CPT, HCPCS, and ICD-10 coding to ensure accurate claims processing.
Reviews and resolves pending claims, identifying errors and determining appropriate corrective action.
Ensures compliance with company policy, provider contracts, and applicable Medicare/Medicaid regulations.
Maintains established quality, accuracy, and production standards.
Processes professional claims across multiple lines of business by reviewing claim and line-level details to ensure accurate adjudication in accordance with established policies and procedures.
Interprets and applies coding guidelines (CPT, HCPCS, ICD-10), benefit plans, and contract language to determine appropriate claim outcomes, including pricing, payment, and denial decisions.
Reviews and resolves claim edits, denials, adjustments, and reprocessing requests by analyzing claim and line-level data, including potential coding discrepancies, system configuration issues, or policy misalignment. Applies benefit plans, reimbursement methodologies, and regulatory requirements to ensure accurate outcomes.
Evaluates pending claims to identify root causes of processing issues, including eligibility discrepancies, authorization requirements, or billing errors, and determines appropriate corrective actions.
Coordinates benefits by reviewing member eligibility, other insurance information, and payer responsibility to ensure accurate application of coordination of benefits (COB) rules.
Reviews provider disputes, reconsiderations, and appeals by analyzing original claim processing, supporting documentation, and applicable policies to determine if reprocessing or adjustment is warranted.
Applies knowledge of reimbursement methodologies, fee schedules, and pricing logic to ensure claims are paid in accordance with contract terms and regulatory guidelines.
Identifies trends or recurring issues in claim processing, including system errors, configuration gaps, or provider billing patterns, and escalates findings to leadership as appropriate.
Communicate effectively with internal teams and providers to clarify claim details, explain adjudication outcomes, and resolve processing issues in a professional and timely manner.
Maintains compliance with HIPAA and protects PHI by ensuring all claim handling, communication, and documentation meet confidentiality and security standards.
Adheres to claim routing, inventory control procedures, and workflow processes to ensure timely and accurate claim processing within established turnaround times.
Participates in ongoing training and continuing education to maintain coding certification and stay current with changes to coding guidelines, reimbursement methodologies, and regulatory requirements.
Maintains punctual, regular, and predictable attendance while meeting established productivity and quality benchmarks.
Respectfully takes direction from Department leadership.