Job Summary
Conducts retrospective review of medical / surgical claims and behavioral health claims for inpatient and outpatient services.
Applies clinical, coding and processing knowledge to conduct review and process claims. Compiles information necessary to prepare cases program payment.
Ensures adherence to program benefits as authorized. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed.
Advises clinical and non-clinical staff on claims and coding questions.
Education & Experience
Required :
- High School Diploma or GED
- 2+ years claims review experience
- Knowledge of all types of Medical claims review
Preferred :
- Claim coding experience
- Knowledge of behavioral health claims review
Key Responsibilities
o Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. CDST and policy keys, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations.
o Validates medical determinations through research of resources including regulatory manuals, computer files and documentation.
o Prepares cases program payment or medical director review as indicated.
o Validates all appropriate data is supplied with program invoice.
o Reviews claim data for process improvements related to all aspects of claims payment.
o Ensures contract compliance for timelines regarding resolution of medical claims.
o Communicates effectively with management and peers.
o Consistently meets medical claims processing quotas.
o Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity as needed.
o Provides support regarding clinical and coding questions.
o Performs other duties as assigned.
o Regular and reliable attendance is required.
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