Under general direction of the Manager, Claims Production and Claims Processing Supervisor, this position is responsible for the accurate review, entry and processing of all claims received for payment by AAH.
Principal responsibilities include:
· Research claims for completion and appropriateness.
· Review and handle rejected claims as necessary.
· Evaluate HealthSuite error screen and base payment determination using AAH claims processing guidelines.
· Utilize Claims Department policies & procedures, workflows and manuals to meet Departmental production and quality metrics.
· Routinely exceed established Departmental individual production standards and collaborate with other Claims staff to ensure departmental compliance targets are met.
· Meet or exceed a financial accuracy standard of 99% and a procedural accuracy standard of 98%.
· Review highly complex claims and edits to determine the appropriate handling for each including paying, denying or suspending for Claims Processing Supervisor review.
· Perform complex adjustments and manually price claims as needed.
· Review high dollar pricing and assist with adjustment projects on an ad-hoc basis.
· Review and resolve Service Requests, as required, within established timeframes.
· Communicate identified issues with claims and claims processes to Supervisor or Manager and propose resolutions.
· Actively participate and collaborate with entire department to continuously improve workflows and performance.
· Perform other duties and special projects as assigned.
EDUCATION OR TRAINING EQUIVALENT TO:
· High School Diploma or equivalent is required.
· 3-5 years as a medical claims processor, meeting or exceeding production and quality standards.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Must have detailed knowledge of CPT, HCPCS, ICD-10 and revenue codes.
· Must have detailed knowledge of CMS1500 and UB04 forms and fields.
· Experience with processing Medi-Cal or Medicaid program claims required.
· Experience in RAM HealthSuite preferred.
· Ability to work in cooperation with others.
· Ability to communicate effectively, both verbally and in writing.
· Ability to handle multiple projects simultaneously and balance priorities.
· Experience in the use of Microsoft Office software (Outlook, Word, Excel).