Processor IV

Job Title

Responsibilities :

Review suspense reason of medical claims and determine actions to be taken to handle edit

Verify information entered in Medical claims system (QNXT) is correct, including patient's name, provider tax identification number and suffix, diagnosis and procedure codes

Access medical claim image and other reference materials as appropriate

Apply contractual benefits, medical policy, and operational procedures to finalize claim

Handle adjustments and reversals of previously paid medical claims as necessary

Review and handle call tracking tickets as assigned

Research eligibility issues in Vitech (V3)

Review and handle EOBs as assigned

Research and complete request refund form

Complete medical inquiry form for Medical Consultant

Handle complex edits and manual pricing

Perform additional duties and projects as assigned by management

Qualifications :

High School Diploma or GED required, some college or degree preferred

Minimum of two (2) years' experience examining and resolving medical claims in a health insurance or benefits environment required

Thorough knowledge of medical claims processing including major medical, office visits, surgery, anesthesia, lab and x-rays required

Knowledge of eligibility systems including Coordination of Benefits (COB) and Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits required

Excellent data entry skills rate required

Excellent oral and written communication skills

Demonstrated organizational skills with ability to multi-task and follow up

Good problem-solving skills with ability to work independently and as a team player

Must meet performance standards including attendance and punctuality