Job Seekers, Please send resumes to resumes@hireitpeople.com Short Description:  The Claims Processor will use knowledge of coding, benefits, provider manual and claims rules / process understanding to make sure claims are accurately processed in a timely fashion.
Complete Description:  This position is in support of the Department of Human Services.
EDUCATION & EXPERIENCE-3-5 years of experience in the healthcare industry  in a claims operations or reviewer roleOR-Equivalent combination of experience, education and training in industry-Certifications (e.g., Certified Professional Coding Designation) preferred
RESPONSIBILITIESAccurate and timely reviews claimsWorks in collaboration with MMIS Operations and HP to process manual claimsAs needed, engage with clinical / medical resources to make accurate clinical and medical necessity determinationsDeep understanding of provider manual, benefit structures and codingAppreciation of one or more ‘pend’ states that require manual adjudication
REQUIRED CAPABILITIESDeep understanding of coding and billing standards (ICD-9, ICD-10, CPT codes, etc.) and medical terminologyUnderstanding of reimbursement guidelinesStrong problem solving skills and inquisitive mindset to help identify and synthesize patterns (e.g., inappropriate practices)Highly driven and motivated to learnExcellent communication skills
JOB MEASUREMENTS & TARGETSTotal claims processed / adjudicated / reviewed Number of opportunities identified and researched from a claims quality perspective

SkillRequired / DesiredAmountof ExperienceMedical Claims ProcessingRequired3YearsICD-9, ICD-10, CPT CodesRequired3YearsMedical TerminologyRequired3YearsCPCDHighly desired