Claims Processor

 

Job Details

Job Location

Any Location/Remote (US) - , OK

Position Type

Full Time

Education Level

High School or Equivalent

Travel Percentage

None

Job Shift

Day

Job Category

Admin - Clerical

WHO WE ARE:

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

WHO YOU ARE:

The Claims Processor is primarily responsible for processing all types of contracted and non-contracted claims accurately and timely for Medicare, Medicaid and Commercial Insurance products. The Claims Processor works directly with the Team Leader and/or Claims Supervisor on the day-to-day operations of the Claims for the purpose of meeting the company, department and regulatory standards for quantity, quality, and timeliness. This position requires the ability to work independently, accomplish goals, excellent customer service and communication skills.

ESSENTIAL JOB FUNCTIONS:

• Processes claims based on the productivity and quality standard set (HCFA1500 and UB92) per day in accordance with contractual and non-contractual agreements and processing guidelines.
• Works with Claims Supervisor or Manager in review of processed and pended claims to ensure appropriate, timely and accurate claims processing.
• Coordinates with Claims Manager on resolution of customer service inquiries within 24 hours of receipt.
• Assist with Claims adjustment projects as requested.
• May help with Claims entry when requested.
• Completes various work assignments as requested by supervisor in a timely manner.
• Maintains current desk procedures and reference materials.
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned.

EDUCATION AND EXPERIENCE:

• High school diploma or equivalent required.
• Two year of medical claims processing experience strongly preferred.

KNOWLEDGE, SKILLS AND ABILITIES:

• Must have full understanding of insurance processes (Managed Care, Medicare, Medicaid and Commercial practices).
• Working knowledge of medical claims processing guidelines and practices.
• Knowledge of Medicare and Health Care Finance Administration regulations.
• Knowledge of EOBs, CPT & ICD-10 codes, HCFAs, UB04s, HCPCS, DRGs and authorizations/referrals.
• Ability to read and interpret provider contracts.
• Strong verbal, written and organizational skills, must be self-directed/self-motivated and must have analytical, problem-solving, and decision-making abilities.
• Accurate keyboard skills.
• Ability to function in a fast-paced, detail-oriented environment.
• Basic math skills.
• High degree of accuracy.
• Team player.

WORK ENVIRONMENT:

• Work is normally performed in a climate-controlled office environment, where exposure to conditions of extreme heat/cold, poor ventilation, fumes and gases is very limited. Noise level is moderate and includes sounds of normal office equipment (computers, telephones, etc.)
• Work involves standing and walking for brief periods of time, but most duties are performed from a seated position. Work may include occasional pushing and/or pulling, lifting, and carrying object weighing up to 20 pounds such as files, documents and computer printouts. Work normally requires finger dexterity and hand-eye coordination to operate a computer keyboard at moderate skill level.

TRAVEL:

No travel is required

SUPERVISORY RESPONSIBILITY:

This position has no supervisory responsibility

OTHER DUTIES:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

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