Claims Processor 1

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave
  
  
  

Summary Statement

This position is responsible for keying paper claims, evaluating and correcting on-line edits that are basic in nature, accessing and applying on-line instructions for the proper resolutions of claims suspension and initiating and responding to written and verbal communications from internal and external sources.

After the appropriate training, incumbents are expected to meet the minimum levels for quality as measured by the Quality and Performance Management department and by the Claims Department.

Essential Duties & Responsibilities

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Prepares first- level (redetermination) case file requests as requested by the Qualified Independent Contractor (QIC) and forwards these case files within the required timeframes established by CMS (Prep and Forward). This includes pulling information from imaging systems, the Multi Carrier System (MCS), letter writer systems, and the Healthcare Integrated General Ledger Accounting System (HIGLAS). Ensures case files that are being forwarded contain the required elements within the case files as outlined in established QIC procedures. (40%)

Resolves basic, on-line edits and performs data entry of hard copy claims. (30%)

Resolve edits on claims suspending on batch edits. (30%)

• Resolve fundamental and basic edits. This may include making basic mathematical calculations such validating accuracy of submitted charges, researching the Inter or Intranets, requesting additional information from the provider, etc.
  
  
  

Performs other duties as the supervisor may, from time to time, deem necessary.

Required Qualifications

• High School diploma or GED
• 6 months’ work experience; this includes data entry experience and working on a PC in a Windows or similar environment.
• Demonstrated mathematical aptitude – ability to add, subtract, multiply and divide.
• Demonstrated effective interpersonal and verbal communications skills.
  
  
  

Preferred Qualifications

• 1-3 years working with medical terminology, procedure and denial codes
• 1 year of experience in claims processing
• 1 year of experience in Medicare Fee For Service
• 1-3 years of experience as data processor
• 1-3 years meeting production and quality standards
  
  
  

The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.

This opportunity is open to remote work in the following approved states: AL, AK, FL, GA, ID, IN, IO, KS, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY.

Specific counties and cities within these states may require additional approval. In FL and PA in-office and hybrid work may also be available.

"We are an Equal Opportunity Employer/Protected Veteran/Disabled"