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:
Authorization verification and readjudication of claim lines.
Anesthesia, Transportation and all others.
QUALIFICATIONS: 2+ years claims processing experience. Computer/Database experience; typing and office skills.
- 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.