Medicare Claims Processor

Job Description:

• Analyze and process Medicare insurance claims in accordance with CMS guidelines
• Determine whether to return, deny, or pay claims according to organizational policies and procedures
• Screen, review, evaluate online entry, correct errors, and perform quality control for final adjudication of paper/electronic claims
• Ensure accuracy of data entered and maintain records
• Analyze claims to determine insurance carrier liability
• Resolve claim edits, review history records, and determine benefit eligibility for services
• Review payment levels and arrive at final payment determinations
• Interpret contract benefits and adjudicate claims according to Medicare claims processing guidelines
• Meet production and quality standards and maintain work queues
• Communicate effectively with internal and external colleagues
• Escalate issues to the next level of supervision as appropriate
• Attend required training and demonstrate proficiency
• Read and interpret explanations of benefits (EOBs)
• Mentor less experienced staff as assigned
• Maintain patient/member confidentiality under PHI and HIPAA guidelines
• Report to the Medicare Claims Supervisor

Requirements:

• Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience
• One (1) year of Medicare claims processing experience
• One (1) year of experience working with CMS/professional and UB/institutional claims
• One (1) year of customer service experience
• Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience (preferred)
• Three (3) years of Medicare claims processing experience (preferred)
• Three (3) plus years of medical or institutional claims processing and customer service experience (preferred)
• Experience in Medicare medical insurance and Medicare supplement preferred
• Familiarity navigating the EPIC software programs preferred
• Ability to sit for extended periods of time
• Comfortable working at times with limited social interaction
• Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records
• Ability to take direction and navigate through multiple systems simultaneously
• Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette
• Ability to solve problems with predefined methods and guidelines
• Ability to use mathematics to adjudicate claims
• Ability to understand medical insurance requirements for payment and basic knowledge of covered services
• Knowledge and understanding of medical terminology, third party payors and insurance preferred
• Attention to detail, organization, independent work, critical thinking, time management, and ability to perform multiple tasks simultaneously
• Working knowledge of Medicare medical insurance terminology, procedure and diagnosis codes, and HIPPA requirements

Benefits:

• Full-time position
• 40 scheduled hours per week