The purpose of this position is to research and provide resolution of all claim issues arising from inquiries from both claims and other departments, including processing and adjusting claims for adjudication.
· Researches claim issues and completes the necessary steps to handle claim adjustments, e.g. appeals, refunds, check reissues, etc.
· Ascertains the nature of the inquiry requiring research, and records pertinence information in the communication log and/or IHIS.
· Researches inquiries utilizing patient history, printed reference material or other related sources.
· Handles and prioritizes various types of issues, including claim and authorization issues, member issues, etc.
· Interfaces with personnel in other departments to resolve issues.
· Contacts internal and external customers as needed to obtain information relating to research, and to report the outcome of the research.
· Conducts necessary follow-up to resolve issues, and maintains acceptable turn-around-time on issue resolution.
· Prepares written correspondence as needed, e.g. overpayment letters, third party liability letters, etc.
· Assists Supervisor and/or Manager with special projects.
· Notifies Supervisor and/or Manager of any issues which may prevent meeting department standards or timelines.
· Requests non-par providers to be added to the system via access provider add table.
· Researches and gathers all documents pertaining to subpoena e.g. claim copy, EOB, CTF, etc.
· Responds to all customers in a professional and courteous manner.
· Tracks and reports errors made by any department for training purposes.
· Provides corrected information to internal and external customers if caller was misinformed on the initial call.
· Provides necessary information to providers needing special assistance.
· Provides tracking sheet to claims coordinator and supervisor daily.
· Attends weekly staff and other meetings to discuss issues and foster teamwork among department personnel.
· Performs other duties and responsibilities as assigned.
· High School diploma or equivalent.
· Minimum 2 years experience with claims processing, computer, 10 key, and typing.
· Knowledge of Microsoft Word and Excel helpful.
· Proficient in MS Office with experience using Word and Excel.
· Familiarity with Managed Care, HMO, PPO health plan provisions.
· Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
· Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
· Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
· Ability to effectively organize, prioritize, multi-task and manage time.
· Demonstrated accuracy and productivity in a changing environment with constant interruptions.
· Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
· Ability to exercise strict confidentiality in all matters.
Mobility - Primarily sedentary, able to sit for long periods of time.
Physical Requirements – Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.
Environmental Conditions - Usual office setting