PURPOSE OF THE POSITION:
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. ESSENTIAL FUNCTIONS:
- 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.