Job Description

Responsibilities:

· Review suspense reason of medical claims and determine actions to be taken to handle edit

· Verify information entered in medical claims system (QNXT) is correct, including patient’s name, provider tax identification number and suffix, diagnosis and procedure codes

· Access medical claim image and other reference materials as appropriate

· Apply contractual benefits, medical policy, and operational procedures to finalize claim

· Handle adjustments and reversals of previously paid medical claims as necessary

· Review and handle call tracking tickets as assigned

· Research eligibility issues in Vitech (V3)

· Review and handle EOBs as assigned

· Research and complete request refund form

· Complete medical inquiry form for Medical Consultant

· Handle complex edits and manual pricing

· Perform additional duties and projects as assigned by management

Qualifications:

· High School Diploma or GED required, some college or degree preferred

· Minimum of two (2) years’ experience examining and resolving medical claims in a health insurance or benefits environment required

· Thorough knowledge of medical claims processing including major medical, office visits, surgery, anesthesia, lab and x-rays required

· Knowledge of eligibility systems including Coordination of Benefits (COB) and Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits required

· Excellent oral and written communication skills

· Demonstrated organizational skills with ability to multi-task and follow up

· Good problem-solving skills with ability to work independently and as a team player

· Ability to work independently and as a team player

· Excellent data entry skills with a minimum 6,000 KPH and 6% or less error rate required

· Must meet performance standards including attendance and punctuality