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
High school diploma or equivalent, required
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.
of working at Children’s Health is the atmosphere of trust within my department. My professional judgment, ethical interaction and desire to work toward positive outcomes for my patients and those I work in conjunction with is not only fostered, it is demanded.