Medical Claims Specialist (WHWC) (Finance)

Department Description:

Claims processing department is responsible for repricing and processing of specialty referral services, medical, dental, medical lab, and diagnostic claim forms for allocation of payment.

Essential Duties:

• Process Medical, Specialty Referral, and Dental Claims and invoices.
• Read, analyze, understand, and ensure compliance with claims/invoicing process.
• Verify approved appointments, approved diagnostic and/or procedures, follow-up care.
• Coordinates and communicates with external and interdepartmental teams to ensure accuracy of claim/invoices to review approved CPT Codes.
• Verifies, processes, and/or adjudicates claims, including applying detailed consideration, standards in claim/invoices for proper application of department policy related to claim entry and analysis; with duties including but not limited to high visibility and sensitivity claim levels.
• Resolution of claims disputes.
• Independently reviews, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
• Review, analyze and reprice claims to approved MHM rates.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Proficient in medical coding and medical terminology.
• Ensures timely and proper arrangement of claims in accordance with coverage amounts.
• Analyze claims for billing inconsistencies and medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Composes and submits denial letters, develops write off letters and confirms services per contracted agreements.
• Proficient knowledge of Microsoft Word, Excel claims.
• Review claim reports to finalize all claim determinations timely.
• Data entry of claim and Explanation of Benefits information.
• Maintains patient confidentiality and complies with all federal and state health information privacy laws.
• Proficient in claims software and Electronic Health Records.
• Performs other duties as assigned.

Qualifications:

Individual must be able to perform each essential duites. The requirements listed above 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.

Skill Development:

Strong verbal and written communication skills, attention to detail, customer service, interpersonal, time management and critical thinking skills.

Education/Experience:

High school diploma or general education degree (GED) required. Minimum 1 year claims processing experience preferred.

Language Ability:

Ability to read, analyze and interpret documents and write detailed correspondence. Ability to provide excellent customer service and to effectively communicate with internal team members and external stakeholders.

Reasoning Ability:

Ability to interpret and carry out instructions furnished in written, oral, and diagram form.

Must understand processes, define problems, collect & interpret data, facts, and obtain valid conclusions.

Mature reasoning skills, demonstrated by consistent professionalism, with an ability to identify and address organizational needs, develop, and justify recommendations, and be responsive and clear in interacting with individuals at all levels, both internally and externally.

Work Environment and Physical Demands:

The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the team member is exposed to a medical office environment. The position necessitates bending, stooping, twisting, turning, walking, climbing step stools, sitting, and standing for periods of time. Must be able to lift and maneuver 25 pounds.