POSITION SUMMARY
The Senior Claims Specialist is responsible for determining the proper payment of medical claims by the group health plan, based upon specific knowledge and application of each client’s customized plan(s).
ESSENTIAL FUNCTIONS
- Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
- Review medical records and other documentation to determine coverage eligibility, coverage limits, and whether a claim is eligible under the terms of the policy.
- Review and understand the terms and conditions of each client’s customized health plan.
- Consult with other entities who can offer additional evaluation of a claim.
- Process claims in the QicLink System.
- Review, analyze and add applicable notes to the QicLink System.
- Document all information gathered in available systems as needed.
- Review billed procedure and diagnosis codes on claims for billing irregularities.
- Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
- Review and process claims reduced through bill review process.
- Review complex health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment.
- Review claim reports and follow up on open issues.
- Assist and support other team members as needed.
- Attend continuing education classes as required, including HIPAA training.
- Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
- Provide insight, guidance and training opportunities within the department.
EDUCATION
High School Diploma, College and Advanced Degrees Preferred
EXPERIENCE & SKILLS
- Knowledge of International Classification of Diseases (ICD) and/or Current Procedural Terminology (CPT) codes required.
- 5+ years required experience analyzing healthcare claims (processing claims)
- Intermediate level work experience with Microsoft Office, Word, Excel and Power Point applications.
- Ability to multi-task, this includes ability to understand multiple products, multiple levels of benefits within each product and work within multiple systems.
COMPETENCIES
- Job Knowledge
- Time Management
- Accountability
- Communication
- Initiative
- Customer Focus
PHYSICAL DEMANDS
- Ability to work with computer-based programs for extended periods of time.
WORK ENVIRONMENT
- Remote