About the position
Responsibilities
• Review claims for duplicates, denials, and referrals, ensuring claims information matches appropriate authorization.
• Prepare cases for Medical Directors, UM Nurses, and Case Managers for clinical review.
• Provide expertise in claims support by reviewing, researching, investigating, negotiating, processing, and adjusting claims.
• Act as a resource for trainers and new hires on benefits, contract interpretations, exclusions, eligibility, and workflows.
• Assist with escalated issues and maintain prompt turnaround time on all claims, handling priority claims within 24 hours.
• Meet department quality and accuracy standards.
• Interface with other departments to obtain necessary information for claims resolution.
• Take ownership of the total work process and provide constructive feedback to minimize problems and increase customer satisfaction.
• Ensure documentation is completed in appropriate systems.
• Prepare and monitor MCR inventory reports to ensure adherence to turnaround time requirements.
Requirements
• High School diploma/GED
• 2+ years of related managed care experience in Prior Authorization or Claim Review healthcare, and/or customer service
• 1+ years in the healthcare industry
• Knowledge of medical terminology, ICD-9, and CPT
• Proficiency with Microsoft Office applications
• Proficient with Medicare processing guidelines and working knowledge of medical contracts
• Ability to work any of the 8-hour shift schedules during normal business hours of 7:00 am – 4:00 pm.
Nice-to-haves
• Ability to organize, prioritize, and communicate effectively.
• Ability to provide excellent customer service to a varied customer base.
• Ability to navigate multiple systems.
• Ability to work in a fast-paced environment.
Benefits
• Comprehensive benefits package
• Career development opportunities
• Flexible work environment with hybrid options