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).
- 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.
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.
- Job Knowledge
- Time Management
- Customer Focus
- Ability to work with computer-based programs for extended periods of time.