Medical Claims Senior Process Executive (Payer)
SUMMARY OF POSITION:
Under the guidance and direction ofthe Team Leader (Claims Supervisor), the primary role of a Senior ClaimsExaminer is that of a superior claims processor with a thorough knowledge ofall claims processing systems, claim processing rules and medical policy. The successful candidate will also possess analytical skills to aid in researchand resolution of Adjustment inquiries and/or correspondences. Theincumbent will also possess a cooperative spirit that will lead to informationsharing with the goal of enhancing the overall performance of the Department. MAJOR DUTIES AND RESPONSIBILITIES: PROFICIENT
in the use of all claim related systems, including ClaimsProcessing System, Claims Workflow, Claims Pricing system, Claims processingrules and Desk Level procedures. INTERPRET
and apply applicable processing guidelines whileinteracting with on-line system edits/pends. RESEARCH
written and/or verbal queries fromproviders/members/internal departments to determine appropriate action on claimand process corrections as required. ANALYZE
patient and medical information to identify instances whereinvestigation for determining appropriate Claim Benefits, Pricing, PriorAuthorization or Coordination of Benefits is necessary and process claimsaccordingly. ADJUDICATE
all claim types, including professional and facility forall lines of business. PROCESS
voids and adjustments as required. MEET
and maintain individual and departmental productivity andquality standards. REVIEW and RELEASE
High dollar claims or other complex claims adjudicated byless senior examiners as directed by the Team Leader (Claims Supervisor) . REVIEW
reports and research pended claims to ensure timelyadjudication within accepted corporate cycle times. Reports include, butare not limited to, daily hot and pend reports, weekly cumulative pend, andother special reports as received from customer. IDENTIFY,
based on review and research of pend reports, and informmanagement of opportunities for quality improvement and best practices ofclaims operations through re-training or system modifications. PROVIDE
special project support. PERFORM
various related duties as assigned.
This description is not anexhaustive list. REPORTING RELATIONSHIP:
Directly reporting to the TeamLeader (Claims Supervisor) QUALIFICATIONS:
Education/Experience: Ideal candidate will possess two or more years of claimsexperience in a managed care or other medical environment to include a minimumof two years medical claims adjudication experience. Two years of collegeis preferred.
Skills/Knowledge/Competencies: The qualified candidate will possess superiorknowledge of all medical claims requirements, including policy and procedures,POS/TOS coding, pricing, and ICD10/CPT coding. The candidate must beknowledgeable about claims processing regulatory requirements, includingcycle-time, and HIPAA standards as they relate to claims. The ability towork with others in a collaborative environment with strong attention to detailis required.
Must be legally authorized to workin the United States without the need for employer sponsorship, now or at anytime in the future.