Job Seekers, Please send resumes to resumes@hireitpeople.comShort Description: The Claims Processor will use knowledge of coding, benefits, provider manual and claims rules / process understanding to make sure claims are accurately processed in a timely fashion.
Complete Description: This position is in support of the Department of Human Services.
EDUCATION & EXPERIENCE
-3-5 years of experience in the healthcare industry in a claims operations or reviewer role
OR
-Equivalent combination of experience, education and training in industry
-Certifications (e.g., Certified Professional Coding Designation) preferred
RESPONSIBILITIES
Accurate and timely reviews claims
Works in collaboration with MMIS Operations and HP to process manual claims
As needed, engage with clinical / medical resources to make accurate clinical and medical necessity determinations
Deep understanding of provider manual, benefit structures and coding
Appreciation of one or more ‘pend’ states that require manual adjudication
REQUIRED CAPABILITIES
Deep understanding of coding and billing standards (ICD-9, ICD-10, CPT codes, etc.) and medical terminology
Understanding of reimbursement guidelines
Strong problem solving skills and inquisitive mindset to help identify and synthesize patterns (e.g., inappropriate practices)
Highly driven and motivated to learn
Excellent communication skills
JOB MEASUREMENTS & TARGETS
Total claims processed / adjudicated / reviewed
Number of opportunities identified and researched from a claims quality perspective
Skill | Required / Desired | Amount | of Experience |
Medical Claims Processing | Required | 3 | Years |
ICD-9, ICD-10, CPT Codes | Required | 3 | Years |
Medical Terminology | Required | 3 | Years |
CPCD | Highly desired |
