Tri-City Medical Center

  • MANAGED CARE CLAIMS PROCESSOR

    Posted Date 1 month ago(1 month ago)
    ID
    2018-6981
    FTE Status
    PD .2
    Shift
    Day
    Cost Center/Dept
    8618 - Managed Care
    Work Schedule
    various schedules during the day from 8:00 to 4:30, 3 to 5 days per week up to 20 hours.
  • Overview

    Position Summary:

    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.

     

    Qualifications:

    • 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.

     

     

    Education:

    • High school diploma or GED required.

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