Claims Processor
Hudson Health Plan - Tarrytown, NY

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Responsible for receiving, analyzing and adjudicating medical and institutional claims.

  • Receive and review medical and hospital claims checking for completeness and compliance with established policies and procedures.
  • Review claims for authorization and member eligibility as necessary.
  • Complete all claims processing functions within the regulated timeframe of 30 days to deny and 45 days to pay.
  • Input claims onto the claims processing system and correct any discrepancies as necessary.
  • Run Batch Control Report and balance payment totals.
  • Work EDE electronic claim queues to correct, modify, transfer to different queue for additional research. Claims Error Queues include but are not limited to:
Provider/vendor selection..

Member selection.

Authorization verification and readjudication of claim lines.

Diagnosis validation.

Anesthesia, Transportation and all others.

  • Identify High Balance claims for management review and approval.
  • Identify Procedures requiring pricing and transfer to EDI Claims Coordinator.
  • Process Coordination of Benefit claims for balance after primary insurance payment, deductibles or co-payments .
  • Access GTESS to verify EDE claim information and update data entries as necessary.
  • Identify unknown EDE providers and vendors, transfer claims to Sr. Research Specialist for research and system update by Provider Relations.
  • Update returned EDE claims from Sr. Research Specialist with corrected provider and vendor data within regulated timeframe.
  • Identify unknown member claims and return to Provider.
  • Complete special projects or research as assigned by the Claims Manager.
QUALIFICATIONS: 2+ years claims processing experience. Computer/Database experience; typing and office skills.

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