Medicare Advantage Claims Processor

ROLE AND RESPONSIBILITIES

Our Medicare Advantage Claims Processor is responsible for analyzing, validating, and adjudicating medical insurance claims by verifying member eligibility, benefits, and authorizations and approving payment or denial according to contractual agreements, policies, health plans, state and federal laws based on CMS in a timely and accurate manner. The incumbent will be responsible for the implementation of new claim processing rules based on CMS contract specifications. Specific responsibilities of the Claims Adjudication include but are not limited to:

ESSENTIAL FUNCTIONS/RESPONSIBILITIES

• Completes accurate analysis of claim determination for payment or denial based on established rules and processes using internal tools.
• Monitor claim inventory of assigned accounts and ensure turnaround and productivity benchmarks are met.
• Processes claims from returned pending claims reports and those containing claim edits.
• Manually prices claim based on specific rates where applicable.
• Audit peer's work for continued cross-training and education.
• Ability to repeatedly produce high-quality results.
• Communicate to Claims Leadership any issues that impede the accurate and timely processing of claims.
• Must be able to apply critical thinking principles to a variety of practical and emergent situations and accurately follow standardized procedures that may require deviations.
• Must be able to apply sound judgment beyond a specific set of instructions and apply knowledge to different factual situations.
• Must always be alert; pay close attention to details.
• Must be able to work under stress on a regular or continuous basis while maintaining focus and control of workload.
• Contributes to and supports the company’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the company’s quality improvement efforts.
• Perform other duties as assigned.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

• Three (3) years of medical claim billing experience with knowledge of CPT and ICD10 codes or Three (3) years of medical claims processing.
• Extensive computer skills, including report generation.
• Preferred knowledge of Medicare claims processing and/or fee schedules
• CPC (Certified Professional Coder) or equivalent is preferred.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Experience:

• medical claims billing: 3 years (Required)
• medical claims processing: 3 years (Required)

License/Certification:

• Certified Professional Coder (Preferred)

Work Location: In person