SUMMARYThis position is intended to provide billing and claims management support to Alivi Specialty Networks and Business Process Outsourcing (BPO) Services. The Medical Claims Examiner will ensure all claims received comply with all health plan, regulatory, contractual, compliance, and Alivi billing guidelines and processes.DUTIES & RESPONSIBILITIES
Responsible for accurate and timely adjudication of professional and institutional claims according to state and federal regulations
Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately
Demonstrate skills in problem solving, benefit plan, and provider contract Interpretation.
Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-10 Codes, under the correct provider contract and member benefits
Responds to provider disputes in a timely and accurate manner.
Research provider disputes to ensure appropriate claims dispute resolutions
Works Directly with Clinical Review Board and Network Operations Team to resolve complex issues or disputes.
Adjudicates claims that have been overturned by the Clinical Review Board or Network Operations Team.
Generates written correspondence to members, providers, and regulatory agencies
Responds and assists other departments with complex issues for resolution or affirmation of previously processed claims and existing guidelines.
Determines and processes overpayments (provider refunds) and reimbursement requests according to specific state and/or federal guidelines or as agreed to in provider contract
Determines and processes underpayments (internal errors) and provider reimbursement requests, which may involve the use of spreadsheet research and correspondence
Maintains the department’s claim edit rules and processing claims according to client specific verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing
Identifies trends in claims flows and suggests process improvements.
Assist in preparation with Claims Audits.
This position description identifies the responsibilities and tasks typically associated with the performance of the position
REQUIREMENTS
High School diploma or equivalent.
3 years’ work experience in claims operations environment in the healthcare insurance processing Medicare
Hands-on working experience processing medical claims in insurance industry
Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees)
Self-starter, ability to work independently and in a team environment
Strategic, analytical, process oriented and must have critical thinking skills
Excellent written and verbal communication skills
Ability to manage multiple priorities
Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities
Works well under pressure
Proficient with Excel, PowerPoint, Word & Outlook
Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes and Revenue Codes
Knowledge of Correct Coding (CCI) Edits
Experience in gathering all necessary documentation in preparation of Delegation Audits.
Detailed knowledge of electronic billing processes universal billing forms
Knowledge of CMS/ACHA Regulations is desirable
Previous Experience using Health Suite is desirable. Certified Professional Coder (CPC) is desirable
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Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Finance and Sales
Industries
Internet Publishing
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