Description/Responsibilities:
The Claims Processor/Adjudicator will review claims for completeness and validity based on verification of eligibility and interpretation of contract benefits and process accordingly.
Essential Duties and Responsibilities:
- Review claims for correct internal data entry and make necessary changes.
- Review claims for correct provider coding information regarding appropriateness of reported services and billing practices.
- Request additional information needed to complete adjudication of claim-e.g., records and/or x-rays, clarification of submitted billing information.
- Review claims for necessity, limitations and exclusions based on claim policies and procedures.
- Determine and enter appropriate benefit/adjudication coding based on subscriber’s plan benefits-e.g. explanation codes, denial codes, pricing structure, accumulators, system overrides.
- Document subscriber, provider and group files when appropriate for audit trail.
- Assist internal associates with claims related questions and issues.
- Identify reoccurring problems and provide feedback to management to effect change.
- Conduct claim specific research to resolve outstanding provider issues
- Research claim issues to identify root cause and determine corrective action to resolve issue, communicate findings, document findings for future use
- Master competency to process OON and MR1 claim queues.
Qualifications:
- High school diploma or equivalent.
- Two or more years of prior experience in health insurance claims processing preferred. Medicare/Medicaid claims experience a plus!
- 2+ years of claim processing experience in HCFA 1500.
- Strong analytical and problem solving skills.
- Excellent communication skills (oral, written, and presentation).
- Ability to manage workflow and meet deadlines on a consistent basis.
- Ability to use Microsoft Office software proficiently.
- Individual must possess proven organizational and interpersonal skills.
- Individual must possess the ability to collaborate with others and work effectively within a team environment.
- Knowledge of medical terminology.
- Ability to interpret varied insurance contracts, both member and provider.
- Ability to work independently and as part of a team to accomplish department goals.
- Ability to handle varied workload.
- Knowledge of ICD-10 and CPT coding a plus!
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The hourly wage for this opportunity is $15.90-18.50. Compensation depends on several factors: qualifications, skills, competencies, and experience.
Tivity Health offers a robust benefits package, which includes a competitive salary, company bonus potential, medical, dental, vision, 401k with match, generous paid time off, free gym membership to over 11,000 fitness locations in the US, and other great benefits.
About Tivity Health® Inc.
Tivity Health® Inc. is a leading provider of healthy life-changing solutions, including SilverSneakers®, Prime® Fitness, Burnalong® and WholeHealth Living®. We help adults improve their health and support them on life's journey by providing access to in-person and virtual physical activity, social, and mental enrichment programs, as well as a full suite of physical medicine and integrative health services. We continue to enhance the way we direct members along their journey to better health by delivering an insights-driven, personalized, interactive experience. Our suite of services support health plans, employers, health systems and providers nationwide as they seek to reduce costs and improve health outcomes. Learn more at Tivity Health.
Tivity Health is an equal employment opportunity employer and is committed to a proactive program of diversity development. Tivity Health will continue to recruit, hire, train, and promote into all job levels without regard to race, religion, gender, marital status, familial status, national origin, age, mental or physical disability, sexual orientation, gender identity, source of income, or veteran status.
