Medical Claims Specialist
3 weeks ago
At Spectraforce Technologies, we are seeking a skilled Medical Claims Specialist to join our team. As a Medical Claims Specialist, you will be responsible for performing medical reviews using established criteria sets and/or performing utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. You will also be responsible for documenting decisions using indicated protocol sets or clinical guidelines.
Responsibilities:
- 80% May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
- Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
- Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
- 10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
- 10% Participates in quality control activities in support of the corporate and team-based objectives. Participates in all required training.
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