Ensure that all claims received are processed accurately and promptly in accordance with program guidelines
Perform quality audits on claims adjudicated by claims processors and/or team leads
Reviewing and addressing provider and customer inquiries externally and internally regarding claim adjudication
Handling escalated, high dollar or complex claims for audit
Developing and maintaining claims operations policies and procedures in the claims operations manual
Resolving pended healthcare claims, prior approval requests and responding to providers
Analyzing claims to determine whether or not the claims should be approved or denied for payment
Applying knowledge of medical coding and various medical claims forms to the claims process
Managing daily workflow for a team of processors, including training of new processors and ongoing updated operational processes
Generating reports and analyzing the data using Microsoft Excel
Auditing the work of claims processors
Subject Matter Expert (SME) for claims processing and adjusting within and outside of the claims team

Karna, LLC

Open Positions (1)