Process incoming claims: Determine correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions. Process all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner. Document provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims. Identify dual coverage, Potential third party savings/recovery. Maintain department databases used for report production and tracking on-going work. Claims are processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)
Perform special projects and ad-hoc reporting as necessary. Projects are complete and reports are generated within the specific time frame agreed upon at the time of assignment. (15%)
Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)
Work with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%)
Attend meetings as required. Claims Department/Operations Division is represented at internal and external meetings. (5%)
Perform other duties as assigned. (10%)