Key skills
Communication
About this role
Role Overview
- 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
Requirements
- High School Diploma Required; Associate degree Preferred
- Requires excellent verbal and written communication skills
- Minimum of 5 years claims processing experience
- Must have prior experience working as a Team Lead or auditor
- Experience in a high-volume claims operations environment
- Microsoft Office skills, particularly Excel