Claim processors will review claim submissions, verify information, adjudicate the claim as per claim processing guidelines to ensure appropriate payment or denial as per the business requirements.
Examining and entering basic claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met
Processing claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit
Approving, pending, or denying payment according to the accepted coverage guidelines
Follows all team procedures, including HIPAA policies and procedures, and meets team quality, turnaround time and productivity performance standards and goals
Identifying and referring all claims with potential third-party liability (i.e., subrogation, COB, MVA, stop loss claims, and potential stop loss files)
Maintaining internal customer relations by interacting with staff regarding claims issues and research, ensuring accurate and complete claim information, contacting insured or other involved parties for additional or missing information, and updating information to claim file with regard to claims status, questions or claim payments
Other duties as assigned
Must be willing to work overtime when the business need requires
High School diploma or GED required
Minimum of two-three years of Medicaid and or Commercial claims payer processing experience
Ability to work independently
Strong attention to detail
Strong interpersonal, time management and organizational skills
Good oral/written communication and analytical skills
Must be able to work in a high-performance environment that changes often
Experience in navigating multiple systems using dual monitors
Knowledge of medical terminology, CPT-4, ICD-9, ICD-10, HCPCS, ASA and UB92 Codes, and standard of billing guidelines required
FACETS experience (highly preferred)
Medicaid knowledge (required)
Keyboard skills of at least 35 WPM + 10-key
Proficient in Microsoft Office - Excel, Word, and Outlook