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 data entry skills rate 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

·Must meet performance standards including attendance and punctuality