Job Summary

The primary function of this position is to process medical claims to completion, ensuring proper payment in accordance with the benefit plan reference and guidelines.

Job Duties & Responsibilities

• Interpreting coding and understanding medical terminology in relation to diagnosis and procedures
• Analyzes and answers inquiries regarding payment, co-pay or deductible amounts, and/or reason for denial.
• Requests all information from internal and outside sources to ascertain completeness and validity of claim including coordination of benefits information.
• Adjudicates for allocation of deductibles, co-pays, co-insurance maximums and provider reimbursements.
• Analyzes the claims to determine extent of liability and settles the claims with claimants in accordance with policy provisions.
• Researches claims as needed, assuring that quality levels are achieved.
• Provides internal customer service to function areas for claim resolution.
• Understands various insurance plans to ensure proper processing.
• Adjusts overpayments, underpayments, and other irregularities.
• Documents phone calls in system and follows up on issues if needed.
• Exceeds productivity and quality standards as they are determined by the business needs on a continuous basis.
• Works closely with Supervisors and Team Leaders.
• Adheres to departmental policies and procedures.
• Follows all procedures to ensure timely accurate claims review, approvals/denials, and payment as required.
• Maintains and promotes positive employee relations in the work environment.
• Works in a safe manner and reports unsafe activity.
• Maintains high levels of safety awareness, a sound safety process to ensure positive team behaviors, and achievement of safety objectives.
• Ensures that the security and privacy policies, standards and guidelines are disseminated, understood and applied in order to protect the informational assets of both the company and their customers.
• Acts in accordance with the organization's information security HR and corporate policies.
• Protects assets from unauthorized access, disclosure, modification, destruction or interference.
• Reports security events or potential events or other security risks to the organization.
• Other tasks duties and responsibilities as assigned.

Experience

• High School diploma or equivalent
• 3 years experience in health care adjudication
• Familiarity with claims processing manuals, medical terminology, and CPT
• codes and basic processing procedures
• Proficiency in the use of claims processing software
• Ability to read, write and speak English
• Prepare accurate and grammatically correct written reports

Physical Requirements

• Physical demands with activity or condition requiring a considerable amount of time include sitting and typing/keyboarding using a computer (i.e., keyboard, mouse, and monitor) or adding machine.Physical demands may include walking, carrying, reaching, standing, and stooping.May require occasional lifting/lowering, pushing, or pulling up to 25 lbs. Repetitive motion is required