Reviewer
AvMed Health Plans - Gainesville, FL

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Claims-Gainesville
Reports to Nicole Carollo

Review and audit all types of contested claims submitted after initial process by our Members or Providers. Make adjustments or send correspondence when necessary.

ESSENTIAL JOB FUNCTIONS:
  • Interpret policy and procedures to properly adjudicate and review all types of claims. Conduct appropriate research and system inquiries in order to obtain claim–related information. Adjust claims as needed, based on appropriate information.
  • Identify and communicate system, provider, and other adjudication problems in an effort to improve first time claim processing accuracy.
  • Conduct an ongoing audit of denied claims to ensure claims compliance with policies and
procedures.
  • Make system inquiries and entries in order to get claims related information.
  • Compose and send letters to providers regarding claim review disposition.
  • Interact with other departments to resolve member and provider issues.
  • Release incorrectly denied claims after pertinent information is gathered.
  • Meet departmental productivity and quality standards.
  • Assist Management with special projects when assigned.
  • Recognizes and observes all company and departmental policies and procedures.
  • Focuses on achieving departmental and organizational objectives.
  • Maintains professional appearance by complying with dress code in an appropriate manner.
  • Complies with company policies and procedures, which includes punctuality as they relate to work time, lunch, and break periods.
  • Assist in training of new personnel.
QUALIFICATIONS:
  • Associate degree preferred or equivalent work experience.
  • Proficiency in Windows and Excel programs.
  • Prior Medical Claims experience.
CRITICAL SKILLS/EXPERTISE:
  • Excellent verbal and written communication skills (including telephone communication).
  • Adjudicating claims or in reviewing claims.
  • Ability to organize work.
  • Ability to understand and apply policies and procedures.
Knowledge of medical terminology.
  • Knowledge of HIPAA Privacy Rules.
  • Knowledge of CPT codes, ICD9 codes and RVS
  • Excellent math aptitude

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