Claims Process Expert
We arelooking for Claims Process Expert: Claims, RCM and Member Services :
Make and Answer calls to and from customers/end users based on agreed time frames.
Transfer calls involving next level of service to the appropriate department as per the given guidelines.
Job Responsibilities :
Develop a complete understanding of the Procedures.
Complete transactions for data preparation, submissions, etc as defined in SOP's.
100% Process adherence to transaction processing timelines.
Adhere to audit compliance ( SAS 70, SOX, Statutory Audit) of all processes as laid out in process documentation.
Ensure process guidelines are followed and met as documented.
Set productivity /Quality benchmark.
Adhere to shift handover processes.
Raise process related issues / concerns on time with process and team leads.
Ensure to meet all Statistical, Financial and TAT metrics.
Stay updated with the process knowledge / changes refer to knowledge updates/ repositories to effectively process transactions.
Adhere to security practices set by organization.
Provide updates and submit reports related to own area of work.
Complete transaction / calls volumes in queue within specified Turn Around Time.
Respond to data requests.
Perform administrative duties which includes maintaining accurate records of information regarding received claims/treatment requests.
Record data relating to production statistics, end-user related notes, etc as appropriate.
Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
Raise process related issues/concerns to team leads/manager.
Adhere to federal, state, URAC, client specified, and established best practices regarding utilization management.
Adhere to program quality standards and maintain acceptable levels of performance, including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
Continuous contribution to process excellence/improvement.