Claims Processing Specialist

2 weeks ago


Charleston, West Virginia, United States CommuniCare Family of Companies Full time

Position Overview:
CommuniCare Family of Companies is seeking a dedicated Claims Processing Specialist to enhance our team. This role is essential in ensuring the accurate adjudication of pharmacy claims and maintaining effective communication with various stakeholders.

Key Responsibilities:
- **Adjudication of Claims:** Manage the processing of daily unit dose and non-unit dose claims efficiently.
- **Insurance Coordination:** Liaise with insurance providers to secure necessary overrides.
- **New Admissions Management:** Oversee new admissions for designated facilities, ensuring all relevant information such as MOP, group codes, tax groups, and patient details are accurately recorded.
- **Family Communication:** Engage with families of new admissions to confirm payment methods when insurance is not available or when there are address discrepancies.

Reporting and Auditing:
- **Weekly Reporting:** Generate and audit the New Admit Report weekly to ensure compliance with all necessary data points.
- **Welcome Packet Preparation:** Assemble and distribute Welcome Packets for all new patients and their families, ensuring they receive essential information.

Documentation Management:
- **Timely Processing:** Ensure that all documents in the ECM Billing folders are addressed promptly.
- **Email Management:** Respond to inquiries sent to the Billing Email in a timely manner.

Authorization Management:
- **Approval Coordination:** Obtain necessary approvals from facilities and families for non-covered medications or those requiring prior authorization.

Batch Management:
- **Monthly Adjudication:** Oversee the monthly adjudication of cycle batches and unit dose reject batches.
- **Customer Notes Management:** Address assigned customer notes promptly and efficiently.

Additional Responsibilities:
- **Hospice and VA Med List Management:** Maintain accurate lists for hospice and VA patients.
- **BI-Call Batch Processing:** Work on any BI-Call batches for facilities as needed.
- **Billing Support:** Assist the billing department with rebilling and managing open billing batches.
- **Issue Communication:** Report any issues that may hinder timely batch postings.
- **Project Assistance:** Contribute to various projects as assigned by management.



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