Review and process provider claims based on provider and health plan contractual agreement, claims processing and reimbursement guidelines, and company policies and procedures. Respond to and resolve provider and health plan claims inquiries and apply resolution in a timely fashion. Maintain departmental standards on productivity and quality of work.
- Analyze and process commercial member claims based on federally and non-Federally- qualified HMO turnaround time guidelines.
- Review services for appropriateness of charges and medical necessity and ensure that prior authorization and pre-certification guidelines are implemented.
- Pay claims based on contractual rates negotiated by Management. Calculate and apply usual, customary, and reasonable rates on non-contracted provider claims, implement Medicare rates on senior member claims from non-contracted and ancillary providers.
- Process and process claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payments, deductibles, etc.
- Acts as a resource and respond to and follow-up on claims inquiries from providers, provider billing offices and health plan representatives.
- Research and adjust claims when appropriate and returns incomplete or incorrect claims to provider with follow up.
- Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines. (Minimum 120 claims per day, with no more than 2% error rate.
- Participate in special projects, complete tasks assigned by management in a timely manner
- Two or more years HMO claims processing experience required in a managed care environment, preferably PMG/IPA setting within the last three years or any combination of education and/or experience which produces an equivalency.
- Must also meet productivity goals of processing a minimum 120 to 160 claims per day with no more than a 2% error rate.
- Knowledge of medical terminology and coding.
- Familiar with CMS and Dept. of Managed Health Care mandates.
- Ability to type 35 WPM, use a ten‑key adding machine, perform data entry and make mathematical calculations.
- Effective communication skills.