Brief job information:
Responsible for the review and processing of complex, specialty 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.
Must possess and consistently demonstrate the following competencies:
Management – Makes the best use of available time and resources. Acknowledges and corrects mistakes. Shows up to work on time, and follows instructions, policies, and procedures. Meets productivity standards, deadlines, and work schedules. Prioritizes tasks by importance and deadline. Displays an ongoing commitment to learning and self-improvement. Desiring and making an effort to acquire new knowledge or skills for work.
Leadership Effectiveness – Leads by example and sets standards for professional behavior. Helps those in need of assistance, regardless of rank. Offers help when needed. Identifies what needs to be done and takes action before being asked or required. Recognizes situations that warrant initiative and moves forward without hesitation. Displays a positive attitude about the work to be done, co-workers, customers, management, and policies. Conveys positive attitude in the process of change.
Decision Making and Judgment – Coordinates ideas and resources to achieve goals. Identifies, collects, and organizes data for analysis and decision-making. Shows insight into the root-causes of problems. Generates a range of solutions and courses of action with benefits, costs, and risks associated with each. Examines data to grasp issues, draw conclusions, and solve problems.
Teamwork – Conveying confidence in co-workers’ ability to be successful, especially with new and challenging tasks. Earns others’ trust and respect through consistent honesty and professionalism in all interactions. Builds constructive working relationships characterized by a high level of acceptance, cooperation, and mutual respect. Maintains an open, approachable manner, and treats others fairly and respectfully. Preserves others’ self-confidence and dignity, and shows regard for their opinions. Promotes cooperation and commitment within a team to achieve goals and deliverables.
Continuous Improvement – Adapting to and working with a variety of situations, individuals, and groups. Demonstrates openness to new organizational structures, procedures, and technology. Openness to different and new ways of doing things. Willingness to modify one’s way of doing things. Diligently attends to details and pursues quality in accomplishing tasks. Develops fresh ideas that provide solutions to all types of workplace challenges.
Communication – Keeps manager informed about progress and problems. Ensures that others involved in a project or effort are kept informed and developments and plans. Allows others to speak without unnecessarily interrupting them. Gives the speaker undivided attention and appears interested in the message (e.g., maintains eye contact, nods). Gets along and interacts positively with co-workers and others. Asks and answers questions that enhance the clarity, quality, and reliability of information.
Work Product Quality – Adheres to all workplace and trade safety laws, regulations, standards, and practices. Displays openness to different or new ways of doing things and sees multiple perspectives. Responds positively to change, embracing and using new practices or values to accomplish goals and solve problems. Respects and maintains confidentiality. Tells the truth and is honest in all dealings. Encourages and supports others at work. Focuses on results and desired outcomes and how best to achieve them in order to get the job done. Willingly puts in extra time and effort in crisis situations; goes the “extra mile” to ensure the goal is met. Defining tasks and milestones to achieve objectives, while ensuring the optimal use of resources to achieve those objectives.
Customer Service – Builds and maintains customer satisfaction with the products and services offered by CCHP. Meeting and exceeding customer needs while cultivating relationships that secure commitment and trust. Seeks customer feedback and ensures needs have been fully met. Be positive when interacting with customers. Delivers products and services when and where the customer needs them. Engages customer in identifying issues, options, and desired outcomes. Develops a clear picture of the needs and best options from the client/customers’ perspective. Remains committed to helping the client long after initial solutions have been applied. Follows up to make sure desired outcomes are realized. Acts proactively, recognizing important trends that will affect customers. Communicates those trends so clients can better prepare to meet new challenges. Develops new services and service models in line with those needs. Anticipates and recognizes the concerns of others, even if those concerns are not openly expressed. Provides excellent services to internal and external customers.
- Proficient 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
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day.
Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.