Medical Claims Specialist

8 hours ago


Costa Mesa, California, United States ICONMA Full time
Job Summary

We are seeking a highly skilled Medical Claims Specialist to join our team at ICONMA. As a key member of our revenue cycle team, you will be responsible for resolving payments and accounts with insurance companies, government payors, and patients.

Key Responsibilities
  • Serve as the account representative for our client, working with payors to resolve claims and accounts.
  • Complete assigned accounts within designated work queues, ensuring timely resolution of payments.
  • Obtain maximum reimbursement by evaluating claims and using contract management tools for proper pricing.
  • Review and initiate appeals for underpayments, adhering to timely requirements.
  • Respond to payor and patient correspondence in a timely manner.
  • Escalate accounts that require appeal due to improper billing, coding, or underpayments.
  • Report new or unknown billing edits to direct supervisor for review and resolution.
  • Possess a strong understanding of revenue cycle processes, from patient access to patient financial services.
  • Have thorough knowledge of managed care contracts, payor rates, and Federal and State requirements.
  • Interpret Explanation of Benefits (EOBs) and Electronic Admittance Advices (ERAs) to ensure proper payment.
  • Understand hospital billing form requirements and familiarize yourself with HCFA 1500 forms.
  • Knowledge of HMO, POS, PPO, EPO, IPA, Medicare Advantage, Covered California, capitation, commercial, and government payors.
  • Demonstrate knowledge of patient accounting systems and accurately code insurance plan codes.
  • Establish payment arrangements for patients unable to pay in full.
  • May review for applicable cash rates, special rates, professional discounts, and process bankruptcy and deceased patient accounts.


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