高级审查员，理赔-必须居住在佛罗里达州
Senior Examiner, Claims-Must reside in Florida
职位描述
职位概述
为索赔审查活动提供高级支持，包括对索赔的裁定进行评估，以识别错误编码、滥用和欺诈性计费行为、浪费、多付款和处理错误。
主要工作职责
• 使用标准原则和州特定法规评估索赔的裁定，以识别错误编码、滥用和欺诈性计费行为、浪费、多付款和索赔处理错误。
• 管理索赔案件量 - 收集所有支持索赔的医疗记录和陈述。
• 为进一步调查和/或解决索赔提供建议。
• 监督缺陷减少工作，通过裁定识别与索赔预付款相关的错误问题，并推荐解决方案以解决问题。
• 识别与索赔预付款相关的错误问题，并推荐解决方案。
• 监控索赔人的医疗治疗；为每个索赔保持详尽的记录和笔记。
• 管理各种类型的复杂索赔案件 - 收集所有支持索赔的医疗记录和陈述。
• 满足州和联邦监管合规要求的处理时间和索赔支付要求，适用于多个业务线（LOB）。
• 满足部门的质量和生产标准。
• 支持所有索赔部门的计划以提高整体效率。
• 完成分配的索赔项目。
所需资格
• 至少2年索赔相关经验，最好在管理护理环境中，或相关教育和经验的同等组合。
• 研究和数据录入技能。
• 组织能力和细致的注意力。
• 时间管理能力，能够同时管理多个项目和任务以满足内部截止日期。
• 有效的口头和书面沟通技能。
• 熟练使用 Microsoft Office 套件和相关软件程序。
优先资格
• 医疗保险索赔/计费经验
· 医疗补助经验
致所有当前 Molina 员工：如果您对该职位感兴趣，请通过内部招聘网站申请。
Molina Healthcare 提供具有竞争力的福利和薪酬包。Molina Healthcare 是平等雇主（EOE） M/F/D/V
最初发布于 Himalayas
查看英文原文
JOB DESCRIPTION Job Summary
Provides senior level support for claims examination activities including evaluation of adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors.
Essential Job Duties
• Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.
• Manages a caseload of claims - procures all medical records and statements that support the claim.
• Makes recommendations for further investigation and/or resolution of claims.
• Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication, and recommends solutions to resolve issues.
• Identifies and recommends solutions for error issues as it relates to pre-payment of claims.
• Monitors the medical treatment of claimants; keeps meticulous notes and records for each claim.
• Manages a caseload of various types of complex claims - procures all medical records and statements that support the claim.
• Meets state and federal regulatory compliance regulations on turnaround times and claims payment for multiple lines of business (LOBs).
• Meets department quality and production standards.
• Supports all claims department initiatives to improve overall efficiency.
• Completes claims projects as assigned.
Required Qualifications
• At least 2 years of experience in claims, preferably in a managed care setting, or equivalent combination of relevant education and experience.
• Research and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.
Preferred Qualifications
• Health care claims/billing experience.
· Medicaid Experience
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Originally posted on Himalayas