Under the direction of the Reimbursement Services Supervisor, and in conjunction with Customer Service this position shall analyze the reconsiderations submitted by providers and/or members to determine appropriate action within Department policy and procedures. This position is responsible for the accurate and timely processing of all medical and dental claims within the Departmental standards and procedures relative to HMO, PPO, TPA and Dental products.
Nature and Scope:
This position shall be responsible to review all member and provider Reconsiderations submitted by Customer Service to ensure disposition and appropriate follow-up action. This position shall make a decision as to what action should take place, ensuring State and Federal regulations are met and provider contract provisions and member benefit plans are adhered to, unless otherwise directed by appropriate health plan management. In conjunction with Reimbursement Services this position shall consult with interdepartmental staff to determine the appropriate course of action to ensure the issue is resolved.
This position will be responsible for processing all adjustment claims; to include voids, refunds, and provider and member appeals. This position will be responsible for reviewing claims that are pended for authorization requirements.
This position is responsible to ensure claims are processed according to Health Plan, Departmental, State and Federal regulations and procedures. This position is responsible to ensure the appropriate member benefits are processed. This position is responsible to research claims as needed in order to adjudicate timely and accurately. This position shall be responsible to complete projects as assigned by the Supervisor or other health plan management. This position shall participate in quality improvement and change management procedures and processes.
This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications: Requirements - Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English. Two-year degree from an accredited college or university or equivalent experience in a healthcare related field.
Three years experience in claims or medical billing, managed care systems, including HMO, PPO, Dental, TPA, Medicare products and which included processing of coordination of benefits and subrogation. Knowledge of CPT, ICD9, HCPCS, ASA, ADA and DRG coding, required. Medical terminology. Ability to understand the technical aspects of managed care systems. Ability to interpret health plan benefits and coverage. Ability to interpret provider contract provisions. Knowledge of state and federal regulations.
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.