医保理赔处理员
Medicare Claims Processor
欢迎！我们很高兴您考虑加入我们！要申请此职位并被考虑，请点击本消息上方的“申请”按钮，并完整填写申请表。以下是对该职位的其他重要信息。
加入我们的WVU Medicine峰健康团队，担任Medicare保险理赔处理员，为一项创新的全新健康计划奠定基础。该职位将向Medicare理赔主管汇报，将在我们改善医疗保健的使命中发挥独特而重要的作用。在医疗行业的工作经验和批判性思维能力将有助于组织建立高效有效的理赔团队。理赔团队审查并监督从简单数据录入到复杂专业理赔研究的各种理赔。Medicare理赔团队分析和处理保险理赔，根据所有CMS指南检查其有效性。必须能够根据组织的政策和程序决定是否退回、拒绝或支付理赔。该工作负责筛查、审查、评估在线录入、错误更正和质量控制，以最终裁定纸质/电子理赔。
最低资格要求：
教育、认证和/或执照：
1. 相关医疗领域的副学士学位，或高中文凭或同等学历，并具有三年医疗理赔和处理经验
经验：
1. 一年Medicare理赔处理经验
2. 一年使用CMS/专业和UB/机构理赔的经验
3. 一年客户服务经验
优先资格要求：
教育、认证和/或执照：
1. 医疗编码或相关医疗领域的学士学位，或四年同等行业的工作经验
经验：
1. 三年Medicare理赔处理经验
2. 三年以上医疗或机构理赔处理和客户服务经验
3. 具有Medicare医疗保险和Medicare补充保险经验者优先
4. 熟悉导航EPIC软件程序
核心职责和责任：此处描述的陈述旨在描述分配到此职位的人所执行工作的总体性质。它们不旨在被构造成所有职责和义务的详尽列表。可能会分配其他职责。
1. 确保数据准确性
查看英文原文
Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.
Come join our Peak Health team at WVU Medicine as a Medicare Insurance Claims Processer, contributing to the foundation for an innovative, new health plan. This position will report to the Medicare Claims Supervisor, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team reviews and oversees the adjudication of claims ranging from simple data entry to complex specialty claim research. The Medicare Claims team analyzes and processes insurance claims, checking for validity in accordance with all CMS guidelines. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluates online entry, error correction, and quality control for final adjudication of paper/electronic claims.MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience
EXPERIENCE:
1. One (1) year of Medicare claims processing experience
2. One (1) year of experience working with CMS/professional and UB/institutional claims
3. One (1) year of customer service experience
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience
EXPERIENCE:
1. Three (3) years of Medicare claims processing experience
2. Three (3) plus years of medical or institutional claims processing and customer service experience
3. Experience in Medicare medical insurance and Medicare supplement preferred
4. Familiarity navigating the EPIC software programs
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Ensure accuracy of data entered and record maintenance
2. Analyze claims to determine the extent of insurance carrier liability
3. Resolve claim edits, review history records, and determine benefit eligibility for service
4. Review payment levels to arrive at final payment determination
5. Interpret contract benefits and adjudicate claims in accordance with the specific Medicare claims processing guidelines
6. Meet all production and quality standards, maintaining Work queues according to department standards
7. Effectively communicate with internal and external colleagues
8. Elevate issues to next level of supervision, as appropriate
9. Attend all required training classes, demonstrating proficiency and the ability to learn
10. Read and interpret explanation of benefits (EOBs)
11. Provide mentorship to less experienced staff as deemed necessary and assigned by leadership
12. Other duties as deemed appropriate by the Claims Supervisor/Manager
13. Maintain strict confidentially of patient/member as specified under PHI and HIPAA guidelines
PHYSICAL REQUIREMENTS: 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.
1. Ability to sit for extended periods of time
2. Comfortable working at times with limited social interaction
WORKING 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.
1. Standard/hybrid/remote office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)
2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access, MS Teams) Internet Explorer and EPIC
SKILLS AND ABILITIES:
1. Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
2. Ability to take direction and to navigate through multiple systems simultaneously.
3. Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette.
4. Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.
5. Ability to use mathematics to adjudicate claims.
6. Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services.
7. Knowledge and understanding of medical terminology, third party payors and insurance preferred.
8. Requires attention to detail, the ability to be organized, ability to work independently, ability to apply critical thinking, time management and to be able to perform multiple tasks simultaneously.
9. Maintain an open, a positive and a collaborative perspective with internal and external colleagues and leadership.
10. Working knowledge of Medicare medical insurance terminology, procedure, diagnosis codes and HIPPA requirements.
Additional Job Description:
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Non-Exempt)Company:
PHH Peak Health HoldingsCost Center:
2902 PHH Claims OperationsOriginally posted on Himalayas