Reviews daily, weekly, and monthly reports to ensure accurate claims processing prior to adjudication. Performs data analysis and review and approval of FW&A recommendations prior to adjudication. Serves as a subject matter expert on claims adjudication for the Medicaid and Medicare lines of business within the health plan.
Department: Ops, Claims
Report To: Mgr, Strategic Operations
Location: Phoenix, AZ 85016
Additional Responsibilities: Candidate Education:
- Handles all claims reports, encounter reversals and E-Status claims review within designated timeframes.
- Reviews, analyzes and makes final acceptance of FW&A recommendations within 24-business hours of response file from FW&A vendor.
- Reviews monthly reports for identification of system enhancements and process changes to ensure accurate adjudication on a go-forward basis.
- Completes daily reports promptly and efficiently, identifying training opportunities, documentation needs, and system updates to minimize future instances.
- Proactively identifies adjustment sources in order to minimize the volume of claims that require secondary handling, generating ideas and creating solutions to improve or simplify procedures, techniques, and processes.
- Researches, reviews and accurately adjudicates CMS-1500 and UB claims of all levels of complexity, correcting claims prior to adjudication.
- Tracks and trends claims processing issues related to auto-adjudication and employee handling of claims, and assists Claims Department in identifying and quantifying issues along with reviewing Claims Department work processes as requested.
- Identifies and assists in conducting additional claims training needed for internal staff as needed.
- Perform other duties as assigned.
- Required A High School or GED
- Preferred An Associate's Degree in a related field
- Required 3 years of experience in claims processing including COB/TPL and claim reversals and adjustments.
- Required 1 year of experience in MHC claims processing
Licenses and Certifications:
- Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Intermediate Demonstrated analytical skills
- Intermediate Demonstrated problem solving skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to multi-task
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Demonstrated organizational skills
- Intermediate Ability to work independently
- Intermediate Demonstrated written communication skills
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Other Attention to detail with high level of accuracy
- Beginner Other Basic knowledge of procedures used in fraud, abuse and waste detection and investigation
- Intermediate Other Knowledgeable in AHCCCS and CMS rules/regulations/reference tools/policy manuals, etc.
- Intermediate Other Detailed understanding of claims processing of institutional and/or professional claims
A license in one of the following is required:
- Required Intermediate Microsoft Excel
- Required Beginner Microsoft Word
- Required Beginner Microsoft Outlook