Claims Representative - Health Plan Job

Children's Health - HMO Careers

Job Number: 50287

Location: Dallas, TX

Date Posted: 12-8-2016

Description:

Position Summary

Research, analyze and adjust paper and/or electronic medical claims. Process complex claims for overpayment, underpayment and refunds. Ensure compliance with provider contracts, state and federal regulations as well as company policies. Utilize knowledge of contracting terms, fee schedules, rates, CPT codes, ICD 10 codes and medical terminology to process claims.

Essential Duties and Responsibilities

Review and research incoming claims by navigating multiple computer systems and platforms

Accurately capture data/information for processing

Verify pricing, resolve prior authorizations and capture applicable benefits for appropriate payment

Meet departmental daily data entry requirements

Communicate claims status for reporting purposes

Learn and leverage new claims systems and training resources appropriately

Research and summarize issues to provide resolution for urgent and escalated issues

Process medical hospital and physician claims

Consistently meet established quality standards, productivity, and scheduled adherence

Qualifications

Education

High school diploma or equivalent, required

Experience

At least 2 years claims experience with government and/or commercial programs, preferred

Moderate proficiency with computers and Windows PC applications, required

Specific knowledge, skills and abilities

Ability to understand both oral and written communication and able to reply in a clear manner when providing explanations, examples, and/or interpretations within claims

Ability to remain focused and productive each day though tasks may be repetitive

Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.

Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.

Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.

Develop and use collaborative relationships to facilitate the accomplishment of work goals.

Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.

Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.

Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.

Effectively manage one's time and resources to ensure that work is completed efficiently.

Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.

Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.

Assimilate and apply new job-related information in a timely manner.

Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

Physical demands

  • Duties require little or no exertion of physical effort.

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