America's Job ExchangeAJE

POSITION SUMMARY: Responsible for receiving, analyzing and adjudicating medical and institutional claims.


SPECIFIC DUTIES:

• Receive and review medical and hospital claims checking for completeness and compliance with established policies and procedures.
• Review claims for authorization and member eligibility as necessary.
• Complete all claims processing functions within the regulated timeframe of 30 days to deny and 45 days to pay.
• Input claims onto the claims processing system and correct any discrepancies as necessary.
• Run Batch Control Report and balance payment totals.
• Work EDE electronic claim queues to correct, modify, transfer to different queue for additional research. Claims Error Queues include but are not limited to:
• Provider/vendor selection..
• Member selection.
• Authorization verification and readjudication of claim lines.
• Diagnosis validation.
• Anesthesia, Transportation and all others.
• Identify High Balance claims for management review and approval.
• Identify Procedures requiring pricing and transfer to EDI Claims Coordinator.
• Process Coordination of Benefit claims for balance after primary insurance payment, deductibles or co-payments .
• Access GTESS to verify EDE claim information and update data entries as necessary.
• Identify unknown EDE providers and vendors, transfer claims to Sr. Research Specialist for research and system update by Provider Relations.
• Update returned EDE claims from Sr. Research Specialist with corrected provider and vendor data within regulated timeframe.
• Identify unknown member claims and return to Provider.
• Complete special projects or research as assigned by the Claims Manager.

Job Benefits