Responsible for the accurate processing and completion of medical claims based defined claims guidelines and policies. Associate can demonstrate proficiency in product lines applicable to the processing unit.
- Process new claims or modifies existing claims according to the appropriate and applicable action
- Analyze claims to determine appropriate action to approve or deny a claim for payment
- Determines accurate payment criteria for clearing pending claims based on defined policies and procedures
- Researches claims edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for entry-level claims
- Reviewing and addressing provider inquiries regarding claim adjudication, and other Claims matters.
- Assisting and or communicate with the Providers to understand the issues on claims brought in.
- Ability to understand and apply knowledge of medical coding (if applicable) and various medical claims forms to the claims process
- Demonstrate ability to work on high volume of repetitive claims
- Demonstrate increasing productivity to meet minimum requirements while maintaining quality standards.
- Ready to work on a fast paced learning process and highly engage to complete the huge backlog of claims.
Education
- Bachelor s Degree holder preferably in the field of Nursing, Healthcare and Allied Medical Profession
- Credential/Professional Certification related to current work is an advantage
Work Experience
- Should have 2 to 5 years of medical claims processing experience
- Experience with medical coding to include diagnosis coding and terminology is an advantage
- Experience in Claims Processing is a MUST.
- Experience in Claims Denials, Appeals and Grievance is highly recommended
Skillset
- Proficient knowledge on US Healthcare Practice, Medical Coding (ICD-10, CPT4, DRG, HCPCS), Clinical Documentation Improvement, medical terminologies, EDI, and HIPAA protocols is a must
- Ability to multi-task and follow documented claims processes with minimal supervision
- Excellent verbal and written business communication skills required
- Strong proficiency in Windows OS and Microsoft Office applications, particularly Excel
- Strong attention to detail and the ability to make appropriate decisions based on information presented