Job Details

Review and accurately process assigned medical claims that pend for manual adjudication in claims processing workflow roles according to member's plan benefits and department claims processing policies and procedures. Verify accuracy of data entry including patient information, procedure and diagnosis codes, amount(s) billed, and provider data. Review plan benefits and determine coverage based on contract and claims processing guidelines. Use Notes system to record pertinent information involving a claim or member. Review claims set-aside for further action and ensure they are released in a timely manner. Document issues that affect claims processing quality and advise team leader of claims processing concerns and/or problems. Provide feedback on standard operating procedures for continual process improvement. Provide assistance to other internal departments in responding to questions regarding claims processing. Provide back-up for Claims Analyst I role. Supporting Responsibilities: R...Claims Analyst, Claims, Processing, Analyst, Staffing, Insurance