Job Description :
Processing basic payments and/or claim denials for group health which includes medical, dental, vision, FSA, HSA, HRA and disability benefits; demonstrating the highest levels of customer service, technical skills and professionalism to ensure mutually rewarding and continued provider relationships.
Examining and entering basic claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met.
Processing claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.
Approving, pending, or denying payment according to the accepted coverage guidelines.
Identifying and referring all claims with potential third party liability (i.e.,. subrogation, COB, MVA, stop loss claims, and potential stop loss files
Maintaining internal customer relations by interacting with staff regarding claims issues and research, ensuring accurate and complete claim information, contacting insured or other involved parties for additional or missing information, and updating information to claim file with regard to claims status, questions or claim payments.
Detailed knowledge of HealthRules software preferred, other transaction system (Facets, QNXT, etc acceptable
The ideal individual will also have excellent oral and written communication skills and the ability to interface with all levels of the customer organization.
This experience will have come from a combination of health plan, software vendor, systems integrator, or consulting organization.
Provides thought-leadership and end user support for a specific application and translates those needs configuration, testing, and implementation.
Participates in application implementations and tests end user processes.
Assists with the creation of presentations and other materials for end user training.
Interacts with clients, both internal and external, to supply information.
Analyzes business and user needs, documenting requirements.
Troubleshooting all claims with potential third party liability, i.e. subrogation, COB, or MVA and stop loss claims and potential stop loss files.
Organizational and time management skills.
Processing complex claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.
Ability to consider IT and business challenges preferred
Knowledge of system development methodology, project management and system architecture. Demonstrated analytical / problem solving skills.
Processing complex claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.
Approving, pending, or denying payment according to the accepted coverage guidelines.
Assisting in training of new groups and new staff as needed; assisting the management team in problem resolution, planning and overseeing workflows; testing and preparing documentation and updating current documentation, as well as providing suggestions and recommendations to improve workflows and departmental efficiencies
TRAINING & EXPERIENCE:
High School diploma and/or 5+ years directly related work experience.
Knowledge of medical terminology, CPT-4, ICD-9, ICD-10, HCPCS, ASA and UB92 Codes, and standard of billing guidelines required.
QicLink experience or certification preferred.
Audit experience required.