ESSENTIAL FUNCTIONS/RESPONSIBILITIES
- Completes accurate analysis of claim determination for payment or denial based on established rules and processes using internal tools.
- Monitor claim inventory of assigned accounts and ensure turnaround and productivity benchmarks are met.
- Processes claims from returned pending claims reports and those containing claim edits.
- Manually price claims based on specific rates where applicable.
- Audit peer's work for continued cross-training and education.
- Ability to repeatedly produce high-quality results.
- Communicate to Claims Leadership any issues that impede the accurate and timely processing of claims.
- Must be able to apply critical thinking principles to a variety of practical and emergent situations and accurately follow standardized procedures that may require deviations.
- Must be able to apply sound judgment beyond a specific set of instructions and apply knowledge to different factual situations.
• Must always be alert; pay close attention to details.
• Must be able to work under stress on a regular or continuous basis while maintaining focus and control of workload. - Contributes to and supports the company’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the company’s quality improvement efforts.
- Perform other duties as assigned.
QUALIFICATIONS AND EDUCATION REQUIREMENTS
- Three (3) years of medical claim-billing experience with knowledge of CPT and ICD10 codes or Three (3) years of medical claims processing.
- Extensive computer skills, including report generation.
- Preferred knowledge of commercial claims processing and/or fee schedules.
- CPC (Certified Professional Coder) or equivalent preferred and required within 12 months of hire.
