The Claims Processor is responsible for accurately and consistently adjudicating claims in accordance with policies, procedures and guidelines as outlined by the company policy. The Claims Processor shall process claims according to all CMS and DMHC guidelines. Investigates and completes open or pended claims. Meets production and quality standards at all times and is familiar with Compliance Standards (HIPAA).
POSITION INTERACTS WITH
ESSENTIAL DUTIES & RESPONSIBILITIES
- Administration Department
- UM/QM Department
- Contracting/Credentialing Department
- Case Management
- Finance Department
- Human Resource Department
- Health Plans
While upholding and supporting the philosophy, objective and policies of Qualcare the essential duties and responsibilities include the following, other duties may be assigned:
- Meets productivity standards for a number of claims completed and for accuracy of entries
- Handles in a professional and confidential manner all correspondence while adhering to HIPAA and Compliance Regulations
- Supports Qualcare core values, policies, and procedures.
- Receives, and adjudicates medical claims for processing; reviews scanned, EDI, or manual documents for pertinent data on claim for complete and accurate information.
- Receives daily workflow via reports or work queue and incoming phone calls
- Researches claims for appropriate support documents
- Analyzes and adjusts data, determines appropriate codes, fees and ensures timely filing and contract rates are applied.
- Responds and documents resolution of inquiries from internal departments.
- Assists Finance with researching provider information to resolve outstanding or stale dated check issues
- Performs Provider Dispute Request (PDR) fulfillment process from the point of claim review through letter processing and records outcome in applicable tracking databases
- Assists maintaining and developing Claims Policies and Procedures
- Must maintain professional etiquette working with external customers and interacting with staff
- Must be proficient in Microsoft Office programs – Excel, Word, PowerPoint, etc
- Must be able to research authorizations, claims, eligibility, and compliance items raised by physician practices or health plan partners.
- Ability to handle provider concerns in an empathetic and caring manner
- Review bills for appropriateness based on individual contracts.
- Re-price medical claims per network provider terms through our EZcap System
- Responsible for answering provider phone inquiries for claims and payment status
- Online data entry of network re-pricing
- Run reports as required
- Deny/misdirect claims to appropriate Payor
- Maintain and follow up on pending claims, as required by guidelines
- Review supporting documentation for accuracy
- Copying, scanning, and filing as required
- Assisting Manager or Director to draft provider documents including formal letters, faxes, certified mail, and drafting of these documents as assigned
- Ensures that payers adhere to compliance laws regarding timely processing of claims.
- Familiar with Claims Reporting guidelines
- Familiar with Eznet and OfficeAlly
- Other duties as assigned by the Manager/Director
- Ability to prioritize and multitask a large work volume with a high level of efficiency and attention to detail
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions
Knowledge of :
- ICD-10, HCPCS, and CPT coding *is a must for contract interpretation and loading*
- Health plan/vendor contracting
- Division of Financial Responsibility (DOFR) and interpretation for accuracy of claims payments
- Company policies and procedures
- Microsoft office applications and Excel spreadsheets specifically: pivot tables, sorting, and filtering
- EZ-CAP System
- OfficeAlly, EDI, Bowman
- DRG/Per Diem/SNF
- Experience understanding / writing algorithmic type logic
- Problem-solve, negotiate and demonstrate independent decision-making
- Prioritize with excellent organizational skills, responding to multiple demands and timeliness
- Demonstrate professional written and verbal communication skills and presentation skills using the English language
- Demonstrate project management skills, including the ability to plan a project and stay within plan and budget
- Demonstrate ability to respond to common inquiries from patients, customers, vendors, regulatory agencies, health plans or member of the business community and possess excellent customer service skills
- Twist, turn and utilize reaching motion, ability to sit and/or stand for extended periods of time
Has knowledge of industry standards and expectations. Has knowledge of commonly used concepts, practices and procedures within this field. Excellent verbal and written skills. Computer literate with knowledge of EZ-Cap and Microsoft Applications. Relies on experience and judgment to plan and accomplish goals. Performs a variety of tasks. Works independently under the direction of the Claims Manager. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
EDUCATION and/or EXPERIENCE
High school diploma and at least (5-10) year related experience and/or training. Experience is mandatory.
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or government regulations. Ability to write reports and/or business correspondence. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations for reporting and actuarial purposes.
Ability to solve practical problems and deal with a variety of concrete variable in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Job Type: Full-time