Claims Processor II

Health One Alliance•Dalton, GA

2d•Onsite

About The Position

The Claims Processor II is responsible for accurate and timely processing of both professional and institutional medical claims pended for manual adjudication in assigned Workflow roles. The Claims Processor II will accurately interpret benefit and policy provisions applicable to fully-insured plan members and review claims to determine coverage based on contract, provider status, and claims processing guidelines. The incumbent must meet quality and productivity standards.

Requirements

High School Diploma or GED required
A minimum of one year experience in claims processing required, must include Professional and Institutional processing
previous experience in medical billing and coding required if no claims processing experience

Nice To Haves

Associates or Bachelor's Degree preferred
Knowledge of ICD-10, CPT4, DRG, HCPCS codes, medical terminology, EDI and HIPAA protocols preferred
Knowledge of UB and HCFA 1500 forms
Certified Professional Coder (CPC) preferred
Experience with Word and Excel

Responsibilities

Reviews and adjudicates claims up to specified dollar limits
Processes claims within performance guidelines of the department, including quality and timeliness
Works with and understands Company benefit plans
Understands provider contracts
Examines and interprets all relevant documents included with the claims
Responds to claim-specific questions, as applicable
Partners with leadership on any questionable claim activity
Understands logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.)
Determines accurate payment criteria for clearing pended claims based on defined Policy and Procedures
Researches claim edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for claims
Works high volume of repetitive claims
Identifies claims with inaccurate data or claims that require review by appropriate team members
Contributes positively as a team player
Completes special projects as assigned and supports other Claims Department team members in assigned projects
Complies with all departmental and Company policies and procedures
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned