Claims Processor

Job DescriptionJob Description

PHYSICAL REQUIREMENTS: Requires prolonged sitting, some bending, lifting, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate office equipment. Requires normal range of hearing and eye sight to record, prepare and communicate appropriate reports.
ENVIRONMENTAL CONDITIONS: This job operates in a professional office environment. Some patient care environment with potential exposure to unpleasant odors, communicable diseases, electrical hazards and other conditions common to a clinic environment. Climate controlled, indoor environment. Occasional exposure to outdoor climate. Work may be stressful at times.
MACHINES/EQUIPMENT USED: office equipment
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES: (This list may not include all of the responsibilities assigned.)
1. Performs a spectrum of clerical chores that culminate in determinations for payment of claims to providers for authorized services rendered; specifically for HMO patients, encounter claims from PCP’s or capitated specialists, ancillary claims, emergency room, shared risk, anesthesia, eye exams claims, and Clinic specialty claims.
2. The processing involves making reasoned determinations as to eligibility for benefits, authorization of services rendered, financial responsibility for the costs incurred, verification of payment-amounts based on contractual agreements with providers, and fulfillment of co-payments or shared risk payments.
3. In addition, answers inquiries from patients, providers and HMO’s regarding status of claims, general payment, benefit, eligibility, and referrals.
4. This position has a direct influence upon both the financial condition of the organization and its’ reputation as a TPA (Third Party Administrator).
5. Maintains the strictest confidentiality in accordance with Sansum Clinic policy.
6. Provides exemplary customer service to patients and staff.
7. Completes special projects as assigned.
8. Works as a team player supporting a variety of staff.
9. Displays a caring and responsive attitude and conducts all activities respecting patient, family and employee rights and expectations.
10. Demonstrates sound cost containment techniques.
11. Adheres to established safety requirements and procedures to ensure a safe working environment.
12. Maintains and evaluates own clinical expertise and practice. Recognizes legal and policy limits of individual practice.
13. Maintains certification and license requirements and submits required evidence of certification/licensure as needed.
14. Adheres to all policies and procedures.
15. Completes annual performance and competency evaluation process with management and participates in goal setting, performance improvement and educational training as needed.
16. Participates in department quality improvement, clinic safety, infection control and hazardous materials programs/activities.
17. Participates in professional development activities and maintains professional affiliations.
18. Attends required meetings and participates in committees as requested.
19. Adheres to HIPAA regulations.
20. Exercises discretion and maintains high level of confidentiality.
21. Performs related work as required.
KNOWLEDGE, ABILITIES, AND SKILLS: This position will have a combination of education and experience to demonstrate competency in the methods, policies, procedures, regulations and protocols of a Claims function. Ability to communicate well with patients, families, co-workers, physicians, other members of the healthcare team, etc. Ability to adapt to varied, age-specific and/or specialized groups. Ability to understand use, function, interpret, document, and keep records. Ability to interpret, adapt and apply guidelines and procedures. Ability to react calmly and effectively in emergency situations. Ability to read, write and communicate effectively in English. Ability to
organize and prioritize work. Ability to follow oral and written instructions. Ability to reason and make sound judgments. Skill in identifying problems and recommending solutions. Skill in establishing and maintaining effective working relationships with co-workers, management, patients, medical staff, and the public. Skill in accepting constructive criticism and giving suggestions in a professional manner.

Company DescriptionAlphaProTemps is specialized in providing "best-in-class" professional staff augmentation services. These recruiting directives include temporary labor, contract sourcing, professional & technical niches, vendor-on-site, and managed service programs.Company DescriptionAlphaProTemps is specialized in providing "best-in-class" professional staff augmentation services. These recruiting directives include temporary labor, contract sourcing, professional & technical niches, vendor-on-site, and managed service programs.

---