Responsible for claims processing and adjudication for managed care risk contracts.
Major Position Responsibilities:
- Date stamp, sort and log claims for processing.
- Maintain/track claims backlog. Report claims backlog information on a weekly basis to Manager.
- Review claims for accuracy and ensure that claims are clean; contact providers as needed to clarify or verify billed services; educate providers on error/omissions in submitted claims.
- Work closely with the Managed Care Contracts Manager in identifying providers with ongoing education and contractual issues for resolution; monitor provider’s progress and update Managed Care Contracts Manager as needed.
- Work closely with medical groups, TCMC Business Office and Utilization Management Personnel to verify member eligibility at the time of service; note if member was properly referred and authorization obtained; verify that services are covered according to the members health plan benefit.
- Identify potential or existing third party liability; coordination of benefits; existing or potential malpractice suits (Class action suits, etc.) communicate liability information to Manager or designee.
- Adjudicate claims payments in compliance with contractual agreements; discuss/verify contractual or rate questions with Managed Care Contracts Manager; maintain an updated matrix of provider contract rates and corresponding services.
- Adjudicate claims in compliance with departmental guidelines.
- Cross train in all appropriate department functions to provide backup as needed.
- Meet specific claims processing productivity targets or requirements (monthly/weekly/daily/) turn-around times, customer response time; identify operational barriers and present potential solutions to Manager.
- Respond to telephone inquiries from members, providers, vendors and internal staff; provide written response as needed in compliance with departmental and health plan policies and procedures.
Safety and Infection Control Responsibilities
Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.
- Minimum two years claims processing or medical billing experience required.
- Knowledge of HCPCS, RBRVS, RVS, CRVS, DRG, ICD-9, ASC and Revenue coding, required.
- Knowledge of managed care risk contracts, preferred.
- Knowledge of managed care provider contracts and health plan benefits, preferred.
- Knowledge of the fundamentals of health care information systems.
- Proficient in Microsoft Word, required.
- Good verbal, written communication and interpersonal skills, required.
- Demonstrated accuracy with numbers.
- Must be detail oriented.
- High school diploma or GED required.