Senior Claims Examiner
W
WelbeHealthHealthcare
Remote, USAFull-TimeSenior
Salary61,663.43 - 81,395.73 USD per year
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Job Details
- Experience
- Three (3) years’ health plan claims processing experience, and two (2) years’ health plan claims dispute experience
- Required Skills
- Microsoft ExcelMicrosoft OfficePowerPoint
Requirements
- Minimum of three (3) years’ health plan claims processing experience, and two (2) years’ health plan claims dispute experience analyzing and resolving provider claims problems
- Experience in a Managed Care Plan (MCP) or PACE organization (PO) claims processing environment highly preferred
- In depth experience with Medicare and Medicaid claims processing
- Strong computer and appropriate software knowledge (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word, Teams) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position
- Ability to balance competing priorities, exercise discretion, and consider all relevant factors in navigating gray areas and resolving ambiguities
- Proficient in the principles and practices of managed health care, health care systems and medical terminology (e.g., revenue Codes, Current procedural Terminology (CPT), Healthcare Common Procedure Coding system (HCPCS) and Internal Classification of Disease (ICD-10)
- Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule and Diagnosis Related Groups (DRG) and benefit interpretation and administration
Responsibilities
- Examine claim records and forms to investigate and resolve first level disputes, including completion of acknowledgement and determination letters
- Review and process second level claims, such as adjustments and corrected claims
- Work closely with leadership on identified trends related to improper processing and claim-related concerns or discrepancies that result in a dispute
- Assist the team in carrying out departmental responsibilities and collaborate with others to support short- and long-term goals and priorities
- Establish and maintain effective working relationships with team and collaboration with interdepartmental staff and leadership
- Work closely with leadership on identified trends related to improper processing and claim related concerns or discrepancies that result in a dispute
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