Job Description
Job DescriptionDescription:
Full-Time (40 hours)
Responsible for reviewing and investigating healthcare insurance claims to determine appropriate contractual payments and adjustments, validity and accuracy
Functions of the Position (not an exhaustive list):
- Investigate claims: Research and evaluate claims for legitimacy and accuracy, which may involve gathering additional information from other parties including payers, providers and other departments
- Contract Management Platform: Use and maintenance of existing contract management software, including uploading, maintaining and removal of payer contracts.
- Reporting: Maintaining, analyzing and providing reporting metrics related to payer reimbursement data in a timely and predictable manner
- Process claims: Analyze insurance claims according to policy provisions and guidelines
- Determine eligibility: Interpret complex policy language and provisions to determine coverage and appropriate reimbursement amounts
- Detect fraud: Analyze claim data and identify irregularities or patterns that may indicate fraudulent activity
Requirements:
Qualification
1. Education:
- High School diploma or equivalent
- Hospital billing experience preferred
2. Physical Demands:
- Requires sitting for long periods; sometimes in a confined space
- Lifting/carry up to 20lbs
- Repetitive finger movement
- Manual dexterity and mobility
- Reaching at all levels
- Stooping, bending, kneeling, crouching
- Work with machinery with moving parts
3. Experience:
- Previous experience in claims processing or medical billing preferred
- Knowledge of policies and regulations: Strong understanding of insurance policies, coverage limitations, and industry-specific regulations (e.g., HIPAA for health claims)
- Claims management software: Proficiency with claims processing and management software
- Data analysis: Ability to collect, analyze, and interpret claims data using tools like Microsoft Excel and other databases
- Medical terminology: Familiarity with medical codes (CPT-4 and ICD-10) for health claims and basic legal principles.