JOB SUMMARY
- Responsible for the accurate and timely adjudication of all claims in accordance with applicable contracts, state and federal regulations, health plan requirements, policies and procedures, and generally accepted business practices.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Reviews providers disputes and appeals, for professional and hospital claims, to determine resolution according to policies and procedures. Adheres to state and federal policies and procedures when adjudicating claims, including but not limited to, interest calculation and resolution timeliness
- Perform any projects delegated by claims supervisor.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims.
- Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology.
EDUCATION / EXPERIENCE
- High School Diploma or Equivalent preferred
- 3-5 years of claims examiner experience preferred
- Minimum of one-year experience handling provider disputes/appeals preferably in a PPO, self-funded, and/or HMO setting preferred
