Responsible for the review and processing of regular claims using established claim standards and departmental policies and procedures ensuring that the work is performed accurately and delivered to meet set objectives.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Accurately evaluates and adjudicates complex claims in a timely manner and according to set standards. Regular claims include but not limited to professional claims, Lab, DME, ambulance, as well as outpatient facility UB claims.
- Able to review and match authorization for the service.
- Assists in optimizing work flows, troubleshooting and problem solving to claims.
- Develop and maintains any/all necessary documentation for claims adjudication
- Identifies and resolves provider billing issues, including provider/vendor communication in writing.
- Ensures accurate interpretation of government laws, rules and any regulations, as well as internal organization guidelines.
- Research, accesses and utilizes on-line reference for claim issues and resolution.
- Assists with completion of claims audits conducted on TPA.
- Accepts and performs other duties as assigned, including frequent special projects.
- Good English (verbal and writing) is required.
- College preferred.
- Insurance claims and Healthcare administration background strongly preferred.
- Strong computer skills required. Any programming / database skill is highly preferred.
Prior Related Experience
- 2 or more years’ experience in health care with complex claims
- Medicaid and Medicare experience preferred
Knowledge, Skills, and Abilities
- Able to work well with others in a collaborative and respectful manner.
- Able to multi-task, deal with complexity on a frequent basis.
- Essential to perform all functions of the job accurately and in a timely manner.
- Able to work under pressure and time constraints.
- Able to arrive for work on time and maintain a good attendance record.
- Ability to maintain a professional demeanor and confidentiality
In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require a medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.