Reviews and investigates claims, processes claims into CCX systems and matches claims data with the appropriate authorizations. Determines correct claims payment or denial. Identifies and evaluates questionable claims and authorizations or system issues as appropriate. Works under close supervision.
• Reviews plans, eligibility, patient notes, and authorizations to determine appropriate adjudication. Creates authorizations when necessary based on individual provider and carrier contracts.
• Reviews electronic claims or processes data as necessary into the claims system, resolves computer generated edit conditions, and determines correct payment or denial amounts and document notes as appropriate.
• Identifies and refers questionable claims, intakes, authorizations, and system issues to appropriate Senior Claims Analyst and then processes responses accordingly.
• Researches and, if necessary, processes claim payment adjustments resulting from customer service referrals, audits or data inaccuracies as detected.
• Exercises good judgment, interprets medical claim data and contracts, and remains knowledgeable in related company policies and procedures.
• Achieves teamwork, production and quality standards in order to assure timely, efficient and accurate claim processing.
• Maintains patient confidentiality and claims integrity in accordance with company policies and procedures.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices. Understands Utilization Management and URAC standards and ensures policies and procedures are followed.
Requires a HS diploma or equivalent; up to 1 year of previous related experience; or any combination of education and experience, which would provide an equivalent background. Experience with claims processing, medical terminology, medical services or equivalent experience required. Knowledge of basic spreadsheet / word processing / data entry and basic math skills required. Knowledge of Utilization Management and URAC standards preferred.
• Candidate will possess excellent communication (verbal/written), organizational and interpersonal skills.
• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
• This position requires excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele.
• Must be able to problem solve difficult situations with internal and external customers, and with process and/or system issues.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.