Job Description

Job Summary:
Reviews claims and makes payment and benefit determination. Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required.
Essential Responsibilities:

• Reviews claims and makes payment determination with authorization limit to $9,999 per claim.
• Conducts research regarding medical appropriateness, coordination of benefits issues, fraud and abuse, and third party liability.
• Checks with Lead and Supervisor for any claim exceeding $9,999.
• Provides input to Supervisor regarding trends related to training, education to enhance department production and processes.
• Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA.
• Proactively works to ensure claims are review & processed timely.

Basic Qualifications:
Experience

• Three (3) to five (5) years Medical claims processing experience in a HMO/Indemnity environment including technical research and analysis experience.
• Claims System OCPS; Windows NT; Word, Excel, Lotus Notes. Excellent skills in communication Medical Claims Processing.
• CPT, ICD-9, Medical Terminology, COB/TPL/WC
• Demonstrate ability to utilize Medical Terminology and International Classification

• Diagnosis (ICD-9), HCPCS&CPT coding at a level appropriate to the job.

Education

• High School Diploma/GED

License, Certification, Registration

• N/A

Additional Requirements:
Preferred Qualifications:

• Medical Terminology Certificate Preferred

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