Claims Processor

Allied Benefit Systems•Chicago, IL

11d•Remote

About The Position

POSITION SUMMARY: The Claims Processor will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client’s customized plan(s). ESSENTIAL FUNCTIONS: Process a minimum of 1,200 medical, dental, and vision claims per week while maintaining quality goals. Read, analyze, understand, and ensure compliance with clients’ customized plans Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto. Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud. Review, analyze and add applicable notes using the QicLink system. Review billed procedure and diagnosis codes on claims for billing irregularities. Analyze claims for billing inconsistencies and medical necessity. Authorize payment, partial payment or denial of claim based upon individual investigation and analysis. Review Workflow Manager daily to document and release pended claims, if applicable. Review Pend and Suspend claim reports to finalize all claim determinations timely. Assist and support other Claims Specialists as needed and when requested. Attend continuing education classes as required, including but not limited to HIPAA training.

Requirements

High School Graduate or equivalent required.
Applicants must have a minimum of two (2) years of medical claims analysis experience (Medicare/Medicaid does not count towards the experience) required.
Applicants must have knowledge of CPT and ICD-10 coding.
Applicants must have strong analytical skills and knowledge of computer systems.

Nice To Haves

Prior experience with a Third-party Administrator (TPA) is highly preferred.
Prior experience with dental and vision processing is preferred, but not required.

Responsibilities

Process a minimum of 1,200 medical, dental, and vision claims per week while maintaining quality goals.
Read, analyze, understand, and ensure compliance with clients’ customized plans
Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
Review, analyze and add applicable notes using the QicLink system.
Review billed procedure and diagnosis codes on claims for billing irregularities.
Analyze claims for billing inconsistencies and medical necessity.
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
Review Workflow Manager daily to document and release pended claims, if applicable.
Review Pend and Suspend claim reports to finalize all claim determinations timely.
Assist and support other Claims Specialists as needed and when requested.
Attend continuing education classes as required, including but not limited to HIPAA training.