Claims Processor Customer Service Analyst - New Port Richey, United States - Evolutions Healthcare Systems

Description

DEPARTMENT:
Claims/Customer Service


MISSION:
"TO PROVIDE INNOVATIVE MANAGED CARE SOLUTIONS FOR THE BENEFIT OF EVERYONE"


REPORTS TO:
Chief Operating Officer


FLSA STATUS:
NON-


EXEMPT PURPOSE

ESSENTIAL FUNCTIONS:

• Process complex claims for physician, hospital, and specialty areas with high degree of accuracy and productivity.
• Process adjustments, according to company policies and procedures.
• Respond timely to written appeals.
• Effective verbal and in written communication skills and provider related issues.
• Answer incoming calls from members, clients, and providers.
• Overtime, as required.
• Attend meetings.
• Other duties may be assigned by Management.

MANAGEMENT/SUPERVISORY RESPONSIBILITIES N/A QUALIFICATIONS, KNOWLEDGE & SKILL To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Minimum Requirements:

o Claims Processing o Customer Service - Resolving and responding to claims and repricing appeals Excellent understanding of o UB04 billing practices and codes including but not limited to Revenue, HCPCS, and MSDRG Codes o HCFA 1500 billing practices and codes including but not limited to CPT and HCPCS Codes o Medicare Modifier Rules - Knowledge of medical terminology and coding rules.

- Computer proficiency and technical aptitude with the ability to utilize MS Office products. - Highly organized and detail oriented.
Able to work and adjust priorities in a fast-paced environment. - Must be willing to accept responsibility and to show good judgment, initiative, honesty, integrity and resourcefulness. EDUCATION - High School Diploma or equivalent. Some college preferred. - Minimum 3 years of experience Medical claims examining/processing - Minimum 3 years of resolving appeals.

LANGUAGE SKILLS Fluency in English spoken and written MATHEMATICAL SKILLS Basic Computational, Statistics & Analytics CERTIFICATE, LICENSES, REGISTRATIONS N/A EQUIPMENT USED Personal Computer (including peripherals such as printers, plotters, etc.), and other Multi-Use Computers (Including Peripherals Such As Printers, Plotters, Tape Drives Etc.), E-Mail, Calculator, Copier, Faxes, Telephone, Shredder PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Sight/Visual/Other Senses:

Use sight to notice changing events in the work environment; use hearing to identify and understand the speech of people; use hearing to notice changing events in the work environment.

WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Control your work pace or schedule of activities within defined perimeters; makes a significant contribution to the organization; works with others on common tasks or projects; perform the same mental activities over and over; perform the same physical activities over and over.

Stress tolerance and flexibility with schedule. Responsibilities sometimes require working evenings and weekends, sometimes with little advance notice.

Evolutions Healthcare Systems is a privately owned Provider Network Development and Management Company, based in New Port Richey, Florida for almost 30 years.

It is a boutique organization specializing in relationship management (aka Customized Network Solutions) for self-funded plans, Hospital Systems, Employer Groups, and TPA's nationwide for Group Health, Workers Compensation (WC), and Medical Auto.

We are seeking individuals who enjoy working independently within a team environment and want to be challenged. We offer industry competitive benefits in a relaxed work environment.