Claims Clerk

nTech Solutions
Washington, DC
29 Jun 2024

Vacancy expired!

Terms of Employment
  • W2 Contract-to-Hire, 4 Months
    • Conversion Salary: $43,027/year
  • Remote (No details, CR to confirm on call)

OverviewThe Claims Resolution Specialist will perform inhouse claims adjudication for complex medical claims. The Specialist will work with Management to improve processes and quality of data for adjudication purposes. The Specialist will provide regular reporting to Health Plan leadership and Provider leadership.

Responsibilities
  • Performs claims adjudication for complex medical claims.
  • Performs regular auditing.
  • Schedules regular meetings with key provider groups to provide reporting and work through claim resolution issues.
  • Handles provider phone calls and emails regarding claims.
  • Meets productivity standards on the number of adjudicated claims.
  • Researches contract terms/interpretation and compile necessary documentation for denial reason validation.
  • Generates weekly Claims Resolution reports for management in accordance with schedule set by supervisor.
  • Generates weekly Provider Claims Resolution logs for Provider Education purposes.
  • Interfaces with Organization’s personnel to include fellow team members, supervisor, managers and customers while maintaining the integrity of claims.
  • Adheres to all federal laws and company policies regarding confidentiality of privileged patient information.
  • Works closely with the Medical Management team on authorization process and auditing.
  • Adheres to company Human Resource policies and understands daily company work requirements.
  • Updates job knowledge by participating in educational opportunities.
  • Enhances organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
  • Examines and resolves non-adjudicated claims to identify key elements of processing requirements based on contracts, policies and procedures. Investigate and perform adjustments of complex claims. Process product or system-specific claims to ensure timely payments are generated and calculate deductibles and maximums as well as research and resolve pending claims. Use automated system processes to send pending claims to ensure accurate completion according to medical policy, contracts, policies and procedures allowing timely considerations to be generated using multiple systems.
  • Does extensive research of procedures to settle insurance claims by approving or denying claims and partnering with Claims Supervisor or Senior Reimbursement Analyst on progress towards claim settlement. May also apply training materials, emails and medical policy to ensure claims are processed correctly. Utilizes the Claims Supervisor or Senior Reimbursement Analyst for assistance on unclear procedures and/or difficult claims and receives coaching from leadership. Establishes insurance losses by evaluating reports and documentation. Documents insurance claim actions by completing logs and files; collecting, analyzing, and summarizing information in reports. Ongoing developmental training to performing daily functions.
  • Completes productivity data/reports daily that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design, financial planning etc.
  • Assists Customer Service Reps by providing feedback and resolving issues and answering basic processing questions. Improves claims adjustment job knowledge by attending training sessions.
  • Other duties as assigned

Required Skills & Experience
  • High school diploma.
  • Medical Billing & Coding Certification
  • Minimum of three (3) years of medical claims processing experience.
  • Ability to travel up to 10%
  • Ability to research Medicaid/Medicare fee schedules for rates.
  • Familiarity and knowledge of APRDRG and EAPG pricing for facility claims
  • Knowledge of Medicaid benefits
  • Ability to present reports to Provider team and Management after research.
  • Top Skills:
    • Claims Processing from the payor side
    • Ability to work without direct supervision
    • Knowledge of ICD-10 and Procedure codes
    • Willingness to learn and ability to demonstrate comprehension
    • Ability to meet targeted deadlines, etc.

Preferred Skills & Experience
  • BA/BS degree
  • Managed Care experience.