Claims Adjudication Specialist

Found in: Talent US C2 - 2 weeks ago

New York, United States MetroPlusHealth Full time

Position Overview

This position is responsible for the data entry and system adjudication of provider claims including but not limited to professional, ancillary and facility claims. The position is responsible for the end-to-end processing of claims.

Job Description

Process claims involving medical and/or surgical services; screens for complete member/provider information Conducts end-to-end processing including ensuring claims are processed timely and accurately in accordance with the system configuration. Assists with the user acceptance process for fee schedule and contract configuration Applies administrative policies when necessary, utilizing the claims processing manuals Generates letters/questionnaires to providers to obtain additional information Responds to internal and external claims related inquiries (written, telephonic and portal) in a timely and compliant manner Processes claims adjustments Conducts research to identify root cause analysis Manages daily claims pended and production inventory Research and resolve inquiries/issues initiated internally (i.e., finance), also by mail, telephone, portal, fax and internal transfers including recoupments, refunds, adjustments and
reconsiderations. Documents, tracks and reports on issues and inquiry resolution Reviews descriptions of services on claims to determine validity of charges of the presence of errors Evaluates and examines claims pended by the system due to contractual and/or payment discrepancies Conducts pre and post adjudication review of claims to verify accuracy of processing Maintains production and quality goals established for the department Performs other related duties, i.e., maintaining individual production counts, updating manuals and reference materials, attending all refresher training seminars

Minimum Qualifications

Associates Degree required; and Minimum 1 year’ experience in claims operations with knowledge of integrated claims processing; or A satisfactory equivalent combination of education, training, and experience Proficiency with data entry Through knowledge of medical terminology, CPT, ICD-p, and Revenue Codes

Professional Competencies

Integrity and Trust Customer Focus Functional/Technical skills Written/Oral Communication

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