Claims processors will be working through a backlog of Commercial claims. Processors will validate the information on all claims from individuals seeking. Claims must be thoroughly reviewed to ensure that there is no missing or incomplete information.
Claims Processors perform a review of front-end claims, and validate the information on all medical claims from patients/providers seeking payment from the insurance company.
Thoroughly review claims to ensure that there is no missing or incomplete information
Review and research assigned claims by navigating multiple computer system and platforms and accurately capture the data/information necessary for processing (e.g. verifying pricing, prior authorizations, etc.)
Ensure that the proper benefits are applied to each claim per claims processing policies and procedures including: grievance procedures, state mandates, CMS guidelines, and benefit plan documents
Review all documentation and determine if a visit was necessary and if policy covers the treatment received to determine if a claim will be paid or denied
Complete denial letters if it is determined that the claim should be denied
Minimum of one year of recent experience processing medical claims working for a health insurance company. Unfortunately, billing side/provider side claims processing is not a fit for this role
Knowledge of medical claim forms (HCFA and UB)
Knowledge of coding (ICD-9, ICD-10, HCPCS, CPT)
Must have strong technical skills (Microsoft Windows, keyboarding skills, strong systems aptitude, advanced Microsoft Excel knowledge, etc.)
Requires excellent verbal and written communication skills
Ability to remain focused and productive each day though tasks may be repetitive