Process incoming claims: Determine correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions; Process all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner; Document provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims; Identify dual coverage, Potential third party savings/recovery; Maintain department databases used for report production and tracking on-going work; Claims are processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)
Perform special projects and ad-hoc reporting as necessary. Projects are complete and reports are generated within the specific time frame agreed upon at the time of assignment. (15%)
Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)
Work with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%)
Attend meetings as required. Claims Department/Operations Division is represented at internal and external meetings. (5%)
Perform other duties as assigned. (10%)