Adjusts and Adjudicates multiple lines of business for first pass in a timely manner to ensure compliance to departmental and regulatory turn-around time and quality standards. Reviews claims and makes payment/adjustment determination to ensure all components, ie., member, provider, authorization, claim and system are valid and correct for accurate processing. Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions to resolve claim. Manages... more details
Description:
Job Summary:
Adjusts and Adjudicates multiple lines of business for first pass in a timely manner to ensure compliance to departmental and regulatory turn-around time and quality standards. Reviews claims and makes payment/adjustment determination to ensure all components, ie., member, provider, authorization, claim and system are valid and correct for accurate processing. Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions to resolve claim. Manages work to meet regulatory guidelines.
Essential Responsibilities:
Reviews claims and makes payment determination with authorization limit to a specific dollar limit (ie. $19,999/claim.).
Checks with Lead and Supervisor for any claim exceeding specific dollar threshold (ie. $19,999).
Reviews and evaluates claims for proper and correct information including, correct member, provider, authorization, and billing information on which to base payment determination.
Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action (i.e. claim reject / denial, request for additional information, etc.).
Conducts research regarding coordination of benefits issues, fraud and abuse, and third party liability.
Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but not limited to CMS, DMHC, DOC, DHS and requirements of accrediting agencies such as NCQA.
Prepares material for audits and provides assistance to Lead and Supervisor during audit.
Assists with the preparation of materials for audits (including Quality, Compliance, and Regulatory audits) and provides assistance to Lead and Supervisor during audit.
Review member/provider claims by checking provider service contracts and other supporting claims documentation in accordance with service agreements.
Coordinates payment agreements with providers, working with appropriate MSA and Regional Contracts Department staff.
Proactively works to ensure claim review is resolved appropriately.
Grade 6
Basic Qualifications:
Experience
Three (3) years medical claims adjudication experience.
Experience in processing multiple types of medical claims and lines of business required (inpatient / outpatient, third party billing, hospital, and professional.)
Education
High School Diploma or GED required.
License, Certification, Registration
N/A
Additional Requirements:
Knowledge of claim processing regulatory guidelines / mandates, ie HIPAA, Timeliness Standards, Medical Terminology, COB / TPL/ WC insurance guidelines.
Knowledge of various payment methodologies & government reimbursement guidelines.
Related Experience Field: Medical Claims Experience.
Working knowledge of CPT, ICD-9, ICD-10, Medical Terminology, COB/TPL/WC. Excellent verbal, written and analytical skills.
Demonstrate ability to utilize Medical Terminology and International Classification Diagnosis (ICD-9, ICD 10) coding at a level appropriate to the job.
Must be able to work in a Labor Management Partnerships environment.
Preferred Qualifications:
Four (4) years medical claims adjudication experience preferred in processing multiple types of medical claims and lines of business (inpatient / outpatient, third party billing, hospital, and professional).
Experience with SNF, DME, or Home Care/Hospice Claims processing preferred.
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