CLAIMS PROCESSOR

Job Description

Job Description

Summary / Objective :

This position is responsible for analyzing and processing facility, ancillary and physician claims, checking them for validity.

Medical claims processor review claims for various items, including appropriate billing practices, and coverage based on the Health and Welfare Guidelines.

The Processor must possess knowledge of medical terms, such as Current Procedural Terminology (CPT), Health Care Procedure Coding Systems (HCPCS) and International Classification of Diseases (ICD-10) to review the claim accurately.

Essential Functions

• Validate information on all medical claims from members and providers seeking payment from their benefits.
• Request required information from both internal and external sources to establish whether the claim is complete and valid.
• Exercise prudent judgement to determine when claims require repricing, case management review, or additional information.
• Communicate effectively with Leadership, cross departments, members, providers, and vendors to expediently handle claim issues.
• Follow appropriate HIPAA guidelines related to patient privacy and confidentiality.
• Attend and participate in Claims meetings for training purposes.
• Meet and maintain production and audit standard quotas.
• Test and verify new or enhanced system applications, if necessary.
• Examine a claim using plan document, supporting documentation, Knowledge Articles, and other resources to make reasonable decisions regarding proper payment of claims.
• Identify billing trends and / or industry changes to notify management.
• Other duties as assigned.

Education and Experience

High School diploma or G.E.D. Certificate.

Specialized skills / technical knowledge required :

• Must have experience with Coordination of Benefits including Medicare.
• Understand Plan eligibility and payment rules including excluded and included covered benefits.
• Must have general medical terminology and anatomy knowledge.
• Must be able to handle a high quality and production environment.
• Appropriate office phone and in person etiquette.
• Knowledge of healthcare coding systems and methodologies such as CPT, ICD-10 and DRG.
• Must have excellent communication (written, verbal, listening), organizational, and problem-solving skills.
• Proficient in Microsoft Office applications.
• Ability to handle multiple tasks in a fast-paced environment.
• Ability to read and interpret medical records preferred by not mandatory.
• Ability to work independently as well as, with others to meet deadlines and resolve any outstanding processing issues.
• Ability to be detailed oriented.
• Must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier, and telephone.
• Knowledge of ISSI or similar claim processing systems.
• Knowledgeable in Salesforce is preferred, but not necessary.
9 hours ago