01Overview
Looking immediate joiners only.
Role & responsibilities
Processes claims in accordance with production, timeliness, and quality standards.
Participates with other internal departments in the resolution of claims issues across department
lines.
Ensures claims are processed in compliance with governmental and accrediting agency regulations.
Ability to read and follow directions
Ensures the delivery of superior customer services by providing timely and accurate
claims payment and responding timely to member and provider inquiries and complaints regarding claims processing.
Develops strong intradepartmental relationships with other department personnel and/or
exempt individual contributors to ensure clear communication and prompt resolution to issues.
Follows departmental policies and procedures regarding claims adjudication.
Ensures that potential fraudulent claims practices are identified and reported to the
Follows all HIPAA compliance guidelines to ensure protection of member protected health
information.
Preferred candidate profile
Understanding of hospital and/or physicians contracts to determine payable benefits and
knowledge of pricing DRG, APC and per diem for all Medical claim products.
Excellent oral and written communication skills including good grammar, voice, and diction.
Able to read and interpret documents and calculate figures and amounts.
Proficient in MS Office with basic computer and keyboarding skills.
Excellent customer service skills (friendly, courteous, and helpful).
High school diploma or general education degree (GED) required
Minimum two years experience in managed care claims processing environment required
Understanding of configuration of claim processing systems and the links between
contracts, utilization management and claims processing within these systems required
An equivalent combination of education, training, and experience. .
