Top notch Claims Processors are needed for a large Northeast Healthcare company. This is a very fast-paced environment where an experienced processor will thrive. The main responsibilities of this position include acting as the liaison between patients and insurance companies, processing insurance claims paperwork and following up on denials. If you enjoy multi-tasking, data entry, helping people and working as a team, apply now! Primary Responsibilities:
· Investigates, reviews, and provides clinical and/or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information. · Performs clinical coverage review of post-service claims, which requires interpretation of state and federal mandates, applicable benefit language, medical reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns. · Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding billing. · Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review. · Maintains and manages daily case review assignments, with a high emphasis on quality. · Provides clinical support and expertise to the other investigative and analytical areas. · Participates in provider/client/network meetings, which may include provider education through written communication. · Participates in training of new staff, and serves as a clinical resource to other areas within the clinical investigative team.