Role: Claims Representative
Duration: 6 months+
Location: Garland, TX 75040
Experience: 6 Months to 6+ Years
Onsite role – There will be a training provide of 2 week and then it will be an Onsite role .
SUMMARY OF POSITION:
Under the guidance and direction of the Team Leader (Claims Supervisor), the Process Executive (Claims Examiner) is responsible for the quality production, adjudication, and cycle time of claims. This position will adhere to all corporate guidelines while processing claims in a timely and efficient manner and placing a strong emphasis on quality work.
MAJOR DUTIES AND RESPONSIBILITIES:
MEET and maintain individual quality and productivity standards and claim cycle time.·
INTERPRET and apply appropriate processing policies, procedures and guidelines while interacting with on-line systems edits/pends.·
PROCESS, review and investigate facility or professional claims by applying appropriate contractual benefit provisions, riders, waivers,· and provider contracts.
PROCESS claim pends to correct and/or finalize the claim on a timely and accurate basis.·
UTILIZE knowledge of procedure codes (i.e. CPT), diagnosis codes (i.e. ICD-9), and POS/TOS codes to render accurate claims decisions.·
ANALYZE patient and medical information to identify whether investigation for Coordination of Benefits, Subrogation, Worker’s Compensation· or No Fault is necessary and to be encountered.
INFORM management of processing, systems, procedural issues and/or problems that may be encountered.·
INITIATE system generated and/or form letters (e.g. requests for Medical Records or claims denials).·
PERFORM various related duties as assigned.·
Responsible for inbound phone inquiries primarily dealing with either I Member benefits and eligibility related to the HMO EPOPPO Medicare and Medicaid CHP and· FHP product lines or II
Provider benefits eligibility PEP and claim status member pharmacy calls utilizing prior approval skills ACPDME and CCD and placing outbound calls on a routine· basis
Resolve issues with respect to benefits and eligibility by researching documentation system information or gaining knowledge from other employees management or· departments Interact with customers document call specifics and demonstrate quality program behaviors to create an outstanding relationship with each caller
Work with outside vendors as needed to answer questions or resolve issues·
Respond to member correspondence / email in writing utilizing an existing CSS system letter to effectively respond to members·
Conduct orientation to new members by providing an overview of the members plan and pertaining administrative policy·
Demonstrate awareness motivation and technical skills to assist in the development and growth of the customer service teams and help to identify process improvements·
Assist in department company projects as needed i.e. provide feedback about the customer’s experience.·
The ideal candidate will demonstrate proficiency in medical terminology, procedure and diagnosis coding in order to ensure comprehension of the overall claims· process.
Familiarity with the universal facility or professional claim/billing forms is required.·
The ability to perform in a high production environment and meet or exceed individual and departmental productivity and quality standards is required.·
Strong written and oral communication skills and analytical ability with attention to detail are essential to success.·
The incumbent must have the ability to work independently to complete assigned tasks.·
EDUCATION and EXPERIENCE
Must have completed at least 2 years of College without back subjects and healthcare insurance experience is a plus·
Must be computer literate and able to multitask ie. document call experience while using the Quality Program·
2 years on claims adjudication experience or in a managed care experience, or comparable experience in medical billing/coding.·
The qualified candidate must be able to successfully complete the Claims Training curriculum.·
Excellent communication and interpersonal skills·
Thanks & Regards,