High School Diploma from an accredited school or equivalent
Minimum of one (1) year medical Claims Examiner processing experience
Proficiency with HCPCS, CPT, ICD-10 coding, UB-04 and CMS-1500 forms
Strong organizational skills and the ability to make good decisions
Requirements:
Resolve system-suspended claims for PCPs, labs, radiology, less complicated specialists, and physical therapy
Deny inappropriate claims following policy guidelines
Review difficult claims with guidance from the Claims Supervisor
Obtain eligibility verification and other health insurance coverage; perform correct manual calculation of benefits when applicable
Job description
Description:
Under management direction, responsible for reviewing and processing all types of medical and facility claims from contracting and non-contracting providers and from subscribers and enrollees for payment in an accurate and timely manner. Responsible for applying correct contract benefits, policies, and procedures. This position is responsible for claims auditing and payment functions for a Knox-Keene licensed health maintenance organization (HMO).
What You Will Do:
Resolve system suspended claims for:
PCPs
Labs
Radiology
Less complicated specialists
Physical Therapy
Deny inappropriate claims following policy guidelines.
Prepare claims that must be routed to other departments for further review.
Review difficult claims with guidance from Claims Supervisor.
Responsible for identifying billing errors and possible fraudulent claims submissions.
Obtain eligibility verification and other health insurance coverage by Internet or POS.
Responsible for correct manual calculation of benefits when applicable.
Responsible for identifying possible CCS eligible claims for further investigation.
Report overpayment refund requests on SharePoint log
Maintain productivity and quality in accordance with established guideline.
Perform other job-related duties as required.Regular Predictable attendance.
Adheres to all company policies and procedures relative to employment and job responsibilities.
You Will Be Successful If:
Computerized on-line data entry systems; organizational structure of medical claims processing; medical terminology; HCPCS, CPT & ICD-10 coding, UB04 and CMS1500 forms.
Adapt to a rapidly evolving work environment; work independently; communicate with a variety of personnel and providers.
What You Will Bring:
High School Diploma from an accredited school or equivalent.
Minimum of one (1) year medical Claims Examiner processing experience.
Individual must have good organizational skills and the ability to make good decisions.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
