Claims Processing Specialist III

Job Summary

Process claims for care provided outside of the company network by reviewing and interpreting the members’ individual benefits and verifying payment of the claim within the terms of the provider’s contract.

Essential Responsibilities

• Process the claim to make sure it is paying correctly. Taking correct co‑pays, making sure provider billed correctly.

• Maintenance of unreleased claims to ensure timely payment. To continue to check pending batches on a regular basis checking for COB information, authorizations being answered, Dictionary issues.

• Maintaining the inventory database making sure that claims that are in a deficiency status are able to be adjudicated.

• Special projects.

• Call tracking‑Making sure that claims are processed and information relayed back to Customer Service. Dictionary Issues‑Claims that are not paying correctly or are coming up deficient are sent to the Dictionary Unit for verification. Auth Issues‑Claim cannot link to auth that is present, but something in the authorization needs to be changed in order for claim to link. These are sent to the coordinator who sends them to RMU.

Job Qualifications

Minimum Qualifications

• Bachelor's degree in business administration or life science & healthcare or related field and three (3) years of overall experience

• In lieu of a bachelor’s degree, equivalent work experience of three (3) years may be substituted for a total of six (6) years’ experience.

• Minimum of 2 years in experience in claims processing

Additional Requirements

• Knowledge of medical terminology.

• Communication and analytical skills.

• Computer skills.

Preferred Qualifications

• Experience in CMS processing HCPCS codes (Ground, Air Ambulance and Ancillary services) using DLP (Desk level procedures)

• Experience with CPT‑4 and ICD 10 coding

• At least 1 year of experience in ambulance claims processing

• Certifications: CPC or CPB