- Review and adjudicate all types of claims designated as "production claims", meeting production and quality goals.
- Review, investigate, and apply all necessary criteria to determine validity of claim.
- Understand the Anthem JAA workflow and apply JAA processing procedures, rules, and guidelines to adjudicate JAA claims.
- Apply benefit plan rules and processing guidelines to pay, pend, or deny claims.
- Manage and follow up timely on all pending claims and correspondence, including review of patient claim history.
- Prepare and generate accurate claim EOB messages and correspondence.
- Review and determine eligibility and coverage for specific group/plan.
- Research claim problems and take necessary actions to resolve.
- Utilize training and on-line documentation to keep up to date on processing guidelines, insurance principles, DOL rules and regulations, and benefit plan rules.
- Update claims system with applicable claim/and patient notes.
- Perform COB, No-fault, Pre-existing, and other claim investigations.
- Contact employers, providers, participants, as necessary.
- Identify correct providers, PPOs, and ensure that appropriate pricing is obtained.
- Perform non-complex claim adjustments, including handling of customer service referrals and take appropriate steps to initiate adjustments on JAA claims.
- Troubleshoot utilization review and medical necessity related issues utilizing AMM or other UR vendor's website information, and route claims for review accordingly.
- Utilize Claim Workflow system for work assignments, routing, and follow up.
- Handle other claim-related duties, projects, and assignments as assigned, including the handling of claim exceptions and provider not found claims.
- One to two years of college or equivalent experience.
- Minimum one years' claims experience.
- Familiarity with Eldorado Software is a plus.
- Medical billing and/or AMA coding experience preferred.
- Data Entry experience or equivalent type work using keyboard/PC.
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Medical Claims Specialist - Valhalla, United States - Stafford Communications
Description
Job Title: Medical Claims Specialist - RemoteStafford Communications is uniquely different. Stafford Communications, a division of Premier BPO specializes in customer service, compliance and marketing in support of many prestigious brands in in pharmaceutical, healthcare, food, consumer packaged goods and beauty care companies - ensuring their customer service initiatives are aligned to their marketing programs.
Job Summary:
The Medical Claims Specialist - Remote is responsible for the review, investigation, decision making, and processing of production claim types, and all related claim functions and activities. Production claims are those claims under $5,000.
Essential Duties and Responsibilities:
•Knowledge of insurance and medical terminology.
•High level of keyboard/PC skills.
•Excellent oral and written communication skills.
•Good judgment and decision-making abilities.
•Good analytical and math skills.
•Good interpersonal skills and willingness to assist others.
•Basic knowledge of Word and Excel.
Pay, benefits and more:
We are eager to attract the best, so we offer competitive compensation and a generous benefits package, including full health insurance (medical, dental and vision), 401(k), life insurance, disability and more.
