RESPONSIBILITIES

Review and modify existing claims according to the appropriate and applicable action Analyze claims to determine appropriate action, to approve or deny action done by the agent Determine if accurate payment criteria for clearing pending claims based on defined policies and procedures were applied Research claims edits to determine if appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for entry-level claims was applied by the claims processor Review if provider inquiries regarding claim adjudication were reviewed and addressed

QUALIFICATIONS

QA experience in claims, understanding QA metrics and KPIs 2 to 5 years of medical claims processing experience Ability to understand and apply knowledge of medical coding (if applicable) and various medical claims forms to the claims process Demonstrate ability to work on high volume of repetitive claims audits Demonstrate increasing productivity to meet minimum requirements while maintaining quality standards Bachelor’s Degree holder preferably in the field of Nursing, Healthcare and Allied Medical Profession Credential/Professional Certification related to current work is an advantage Experience with medical coding to include diagnosis coding and terminology is an advantage Knowledge in US healthcare practice, medical coding (ICD-10, CPT4, DRG, HCPCS), clinical documentation improvement, medical terminologies, EDI, and HIPAA protocols Ability to multi-task and follow documented claims processes with minimal supervision Excellent verbal and written business communication skills Strong attention to detail Ability to make appropriate decisions based on information presented