Job Description
Job Description
Primary Responsibilities
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Review and adjudicate claims submitted for reimbursement that fall outside auto adjudication standards on a daily basis, ensuring compliance with quality, productivity, and timeliness requirements.
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Applying medical policies, contractual provisions, and operational procedures to ensure precise adjudication and adjustments.
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Generate correspondence, such as letters and questionnaires, to gather additional information from customers and providers; may also initiate phone inquiries.
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Collaborate with Customer Service to address and resolve customer inquiries and concerns effectively.
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Research and resolve client inquiries and escalations in a timely manner, collaborating with internal teams as needed to ensure effective resolution.
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Execute client-requested claim adjustments and provide clear, concise written responses to client inquiries within established deadlines.
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Perform in-depth research on account receivables and spreadsheets that require claim adjustments, delivering thorough and clarifying responses to providers and clients.
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Must be adaptable and willing to provide backup support across various departments and roles as needed
Essential Qualifications
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Strong knowledge of healthcare contracts, medical terminology, and claims processing procedures.
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Prior experience processing claims is required.
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Minimum 1 year of experience in medical billing, claims adjudication, or a related role.
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Excellent written and verbal communication skills, with the ability to manage inquiries professionally and efficiently.
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Strong analytical skills with the ability to research and resolve complex claim issues.
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Proficiency in Microsoft Office Suite, particularly Microsoft Word and Excel.
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Ability to meet production and quality standards while managing multiple priorities.
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Strong problem-solving skills and the ability to maintain professionalism under pressure.
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