Responsibilities : Enter claims data in claims processing system and review entry for correct adjudication according to patient benefit coverage and provider contracts.
Responsible for following applicable regulatory and internal policies in claims adjudication.Investigate and research claims as necessary to determine or verify members’ eligibility, benefit coverage and required authorizations.
Deny unauthorized and / or ineligible claims according to client’s guidelines (provider denials vs. member-liability denials).
Ensure claims payment & denial accuracy and turnaround time.Review, Evaluate and Process all types of claims such as Encounter data, Professional and Institutional Claims for all lines of business e.
g., Commercial, Point of Service (POS) Senior / Medicare, Preferred Provider Organization (PPO), Medi-Cal, etc. Requirements : College Graduate preferably from Allied Medical CourseExperience in HMO industry or medical claims processing required Ability to analyze data to determine problems and suggest solutionsAbility to work under pressure and manage a large workloadAbility to adjust to changes in method, processes and proceduresAbility to navigate multiple software applications simultaneouslyAbility to work independently and effectively under pressureAssertive, self-directed, and resourcefulWilling to work on Graveyard Shift (GY)