Job Description:
• Analyze and process a variety of complex medical claims in accordance with program policies and procedures, ensuring accuracy and compliance.
• Adjudicate claims according to program guidelines, applying critical thinking skills to navigate complex scenarios.
• Ensure prompt claims processing to meet client standards and regulatory requirements.
• Identify and resolve any barriers using effective problem-solving strategies.
• Collaborate with internal departments to proactively resolve discrepancies and issues.
• Use analytical skills to identify root causes and implement solutions.
• Uphold confidentiality of patient records and company information in accordance with HIPAA regulations.
• Maintain thorough and accurate records of claims processed, denied, or requiring further investigation.
• Analyze and report trends in claim issues or irregularities to management.
• Assist Team Leads with reporting to contribute to continuous process improvements.
• Engage in audits and compliance reviews to ensure adherence to internal and external regulations.
• Critically evaluate and recommend process improvements when necessary.
• Mentor and train new claims processors as needed.
Requirements:
• High school diploma or equivalent.
• Minimum of five years of experience in medical claims processing, including professional and facility claims, as well as complex and high-dollar claims.
• Familiarity with ICD-10, CPT, and HCPCS coding systems.
• Understanding of medical terminology, healthcare services, and insurance procedures (experience with worker’s compensation claims is a plus).
• Strong attention to detail and accuracy.
• Ability to interpret and apply insurance program policies and government regulations effectively.
• Excellent written and verbal communication skills.
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook).
• Ability to work independently and collaboratively within a team environment.
• Commitment to ongoing education and staying current with industry standards and technology advancements.
• Experience with claim denial resolution and the appeals process.
• Ability to manage a high volume of claims efficiently.
• Strong problem-solving capabilities and a customer service-oriented mindset.
• Flexibility to adjust to the evolving needs of the client and program changes.
Benefits:
• 401(k) with employer matching
• Health insurance
• Dental insurance
• Vision insurance
• Life insurance
• Flexible Paid Time Off (PTO)
• Paid Holidays