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Claims Approver

Bronx, New York
Job Type
13 Sep 2020


Review and process Facility and Professional claims inclusive of In-patient and Out-patient UB04 forms and all other Professional services billed on CMS 1500 forms for services rendered to Medicaid, UniCare, Family Health Plus and Child Health Plus Members.


  • Review claims for billing, coding accuracy and completeness.
  • Process in accordance to all Plan, Federal and State provisions.
  • Evaluate claims for and report out suspected fraud, waste and abuse.
  • Use enterprise claims processing platform and ancillary supporting data bases and systems to research and/or retrieve key information necessary to support claims processing.
  • Meet or exceed productivity and quality expectations as detailed in the Claims Department Performance Plan.
  • Represent and demonstrate a thorough knowledge of both medical and hospital claims billing requirements, regulatory guidelines and the Plan Benefits applicable to each of the Affinity Health Plan product lines of business.
  • Identify problems or questionable claim situations, resolve issues where appropriate, and refer to Claims Resolution Specialist for guidance.
  • Generate letters requesting additional information required to support proper claim determinations as well as denial letters to providers and Members as deemed appropriate.
  • Work cooperatively with Staff throughout the company and contribute to the overall success of the Claims Department.
  • Prepare weekly/monthly reports of claims activity, tracking claims processed against performance plan goal. Complete and submit all reports or other documentation required by Management, in a timely manner.
  • Perform other duties as necessary or required.


  • High school diploma or GED; Associates Degree preferred.
  • Previous experience in a Medicaid managed care environment with a minimum of one year of claims processing experience preferred.
  • Strong keyboard skills preferred (ability to accurately process 45+ wpm)
  • Experience processing claims in enterprise managed care data base systems, ideally Facets claims processing.
  • Strong analytical, organizational, problem solving and prioritization skills.
  • The ability to work independently, proactively and function well under pressure.
  • Ability to successfully organize work and effectively manage claim volume.
  • Ability to communicate clearly and effectively, both verbally and in writing.
  • Basic proficiency with Microsoft Office (Word, Excel, Power Point, etc.) including data entry skills and experience.
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  • Job Reference: 173900196-2
  • Date Posted: 13 September 2020
  • Recruiter: Affinity Health Plan
  • Location: Bronx, New York
  • Salary: On Application
  • Sector: I.T. & Communications
  • Job Type: Permanent