What are important things that YOU need to know about this role?
- This is a fully remote position
- You can choose your 8 hour shift between 7am-5:00pm, Central Time
- Depending on work load, There may be times when overtime will be required
What will YOU be doing for us? Ensure accurate and timely payment of claims to medical providers. Utilize research and knowledge of coverage and benefits to ensure resolution to more difficult claim payment issues.
What will YOU be working on?
This list of duties and responsibilities is not intended to be a complete list of all the duties and responsibilities performed by incumbents. Duties, responsibilities and expectations may be added, deleted or modified at any time at the discretion of the supervisor.
- Submit accurate and timely payments to providers, keeping within contractual service level agreements for each market. Develop and maintain controls over the proprietary processed data and systems set up through developing and implementing auditing procedures, and identifying potential claim audit exposures.
- Interpret and understand coverage and benefit limitations by having a comprehensive understanding of benefits and state requirements for multiple markets.
- Assure that claims are paid within the expected time frames by monitoring inventory control and working with team members and appropriate resources in other areas to resolve issues related to claims entry.
- Identify trends and suggest and develop efficiencies in the review of edit reports and other documentation by reviewing procedures and making appropriate suggestions and adjustments to procedures.
- Resolve complex claim payment inquiries by analyzing patient activity and related documentation (including enrollment, claims, and authorizations) and determine appropriate action to be taken.
- Resolve complex client issues that may require research, analysis and working with management.
- Complete requests for claims review and/or reprocess within internal guideline turnaround times.
Additional Responsibilities:
- Develop and maintain client and provider relationships by interacting directly with the client and providing necessary feedback and communications as needed.
- Provide training and guidance to team members on market specific issues by providing feedback to management on claims and provider issues, and updating client business rules and check run procedures as needed.
- Partner with Reimbursements team Assist in completing all other tasks as necessary to ensure accurate and timely check runs and internal turnaround times.
What qualifications do YOU need to have to be GOOD candidate?
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 the essential functions.
- Required Level of Education, Licenses, and/or Certificates
- High school diploma or equivalent
- Required Level of Experience
- 2 years of prior job related experience (Medical Assistant, Medical Office Manager, medical front office, or health/dental insurance, including managed care operations, accounts receivable and or billing)
- Required Knowledge, Skills, and Abilities
- Knowledge of health or dental procedures coding and terminology.
- Basic knowledge of Microsoft software (Outlook, Excel and Word).
- Exceptional written and verbal communication skills.
- Competencies
- Fostering Innovation: The ability to develop, sponsor, or support the introduction of new and improved method, products, procedures, or technologies.
- Critical Thinking: The ability to analyze/evaluate information as presented, utilize past experience to make decisions that are logical and reasonable and demonstrate sound judgment.
- Initiative: Identifying what needs to be done and doing it before being asked or before the situation requires it.
- Results Orientation: The ability to focus on the desired result of one’s own or one’s unit’s work, setting challenging goals, focusing effort on the goals, and meeting or exceeding them.
- Detail Oriented: Ensuring that one’s own and/or others’ work and information are complete, timely and accurate; carefully preparing for meetings and presentations; following up with others to ensure that agreements and commitments have been fulfilled.
- Time Management: The ability to manage several competing tasks at once effectively while still meeting deadlines.
What qualifications do YOU need to have to be a GREAT candidate?
- Preferred Level of Education, License, and/or Certificates
- Bachelor’s Degree in a related field
- Preferred Level of Experience
- Knowledge of vision claim processing
- Preferred Knowledge, Skills, and Abilities
- None