Claims Processor

This role is responsible for submitting claims in accordance with payer regulations and applicable guidelines. The incumbent will facilitate the overall claim process through submission of both electronic and paper-based claims, resolution of claim-form edits and validation of data integrity.

• Transmit and retrieve electronic patient claims/files to and from the claims clearinghouse in accordance with established procedures.
• Review claims for all necessary requirements for billing, including complete patient and insurance information; complete paper claim processing in a timely and accurate manner.
• Resolve all claim edits, in both the billing system and the clearinghouse, accurately and timely through attention to detail and critical thinking skills in accordance with payer regulations and guidelines.
• Identify and research unusual, complex or escalated issues as assigned; apply problem-solving and critical thinking skills as necessary to resolve issues within the scope of position authority.
• Document all activities and findings in accordance with established policies and procedures; ensure the integrity of all account documentation; maintain confidentiality of medical records.
• Maintain current knowledge of internal, industry, and government regulations as applicable to assigned function.
• Perform other duties as assigned by management.

The ideal candidate will possess knowledge of general concepts and practices that relate to the healthcare field, and specific policies, standards, procedures and practices that pertain to the assigned function. Additionally, they will have knowledge of medical insurance, CPT and ICD codes, clinic operations related to patient registration, referrals and cash collections, general office principles, practices, standards, systems and tools/equipment, medical insurance, payer contract, and basic medical terminology and abbreviations.

The candidate will also be able to enter data in accordance with established standards of timeliness, accuracy and productivity, understand and apply detailed billing requirements and insurance follow-up practices, keep abreast of trends, developments and changing regulatory requirements that impact matters within designated scope of responsibility, identify and articulate non-compliance with established guidelines and/or regulatory requirements, troubleshoot, understand and/or adapt moderately complex oral and or written instructions/guidelines to diverse or dissimilar situations, maintain confidentiality of medical records, and use discretion with confidential data and sensitive information.

The candidate will also be able to demonstrate attention to detail and critical thinking skills within the context of the assigned function, with a commitment to accuracy, effectively prioritize and execute tasks while under pressure, make decisions based on available information and within the scope of authority of the position, demonstrate excellent customer service skills, including professional telephone interactions, read, understand and communicate in English sufficient to perform the duties of the position, establish and maintain effective working relationships as required by the duties of the position, and use office equipment and automated systems/applications/software at an acceptable level of proficiency.

PREFERRED Qualifications include graduation from a post-high school program in medical billing or other business-related field.