at Position Description: Reviewing claims working off project list or work queue. Responsible for providing expertise or general support in reviewing, researching. Experience in a production based environment with an emphasis on quality outcomes. Primary Resposabilities: * Reviewing and adjudicating medical claims in accordance with CMS claim processing guidelines. * Processing claims Up to 50K * Provide expertise claims support by reviewing, researching, investigating, auditing claims * Analyze and identify trends and provides feedback and reports to reduce errors and improve claims processes and performance * Responsible for all aspects of quality assurance * researching and processing complex claims and approving, denying or send claims to Correct area for further reasearch * Processing replacement for corrected claims and adjusting original claim * Accurately process institutional (hospital) claims. * Accurately process claims billed on UB04 Claim forms and HCFA claims forms. * Maintaining/meeting compliance time-frames. * Responsible for editing and adjudicating claims. * Analyze claims to ensure accurate billing and payment. * Interpret contracts and fee schedules. * Meet department accuracy and production standards. * Interface with other departments to obtain necessary information required for resolution of claims. * CPT, ICD-9 Volumes 1,2, 3 and HCPCS coding * Revenue centers associated with billing * Hospital, ambulatory surgery center, home health, skilled nursing and dialysis claims other locations etc. * Division of Financial Responsibilities (DOFR) * Understanding of Stop Loss * Claims processing manuals for different States * independently complete assignments consisting of numerous steps that vary in nature and sequence. * select from alternative methods and refer problems not solvable by adapting or interpreting substantive guides, manuals, or procedures.Process health-based related data in systems, while maintaining production and quality standards * Research and resolve problem claims when encountered. * Report document discrepancies with suggested resolutions to appropriate departments * Communicate with internal staff, and groups as needed to complete processing work * Handle assignments that are complex and high dollar * Monitor, schedules and manage work flow and priorities whole maintaining communication with supervisor and team members Starting Position- Lead Clinical Appeals Representative 800-996-7566 or TTY 800-424-0253

Highlights:

• Microsoft
• Microsoft Outlook
• Services
• Adobe
• Audit
• Banking Industry
• Benefits
• Billing
• Call Center
• Cardiopulmonary resuscitation (CPR)