Roles and Responsibilities
- Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
- Follows established policies and procedures to pay, pend for additional information, or deny claims.
- Process claims subject to Coordination of Benefits (COB) according to plan benefits, COB rules and contractual reimbursement terms
- Accountable to meet and maintain established department production and quality standards.
- Create claim test cases, execute, and report on the results.
- Identify and communicate defects or claim system issues to those responsible for configuration.
- Work with configuration to remediate and retest defects.
- Identify and communicate inventory issues to department’s management.
- Works with internal departments, vendors, business partners, providers, etc. to help coordinate problem solving in an effective and timely manner.
- Develop and maintain desk top procedures related to claim adjudication.
- Audit auto-adjudicated and/or manually processed claims.
- Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins.
Experience and Skills Desired
- You have a minimum of 3 years' medical claim adjudication/examination experience, working within a health insurance carrier, health insurance TPA, or equivalent.
- You have knowledge of medical and insurance industry terminology including CPT/ICD-10, HCPCS and Revenue Codes.
- You possess strong attention to detail and problem-solving skills with a high level of accuracy.
- You have experience writing desk top procedures.
- You are an excellent communicator, both verbally and in writing.
- You can perform comfortably in a fast-paced, deadline-oriented work environment.
- You are proficient in Microsoft Office applications Word, Excel, Outlook OneNote, etc.
- You have prior experience using a CRM, preferably Salesforce.
- You have prior experience with claim testing and or/auditing.
- You collaborate and support business and operational units such as Customer Service, Medical Management and Appeals and Grievance.
- Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred.
- Bonus: Plexis/Quantum Choice experience.
Benefits Package
- Competitive salary
- Comprehensive health, dental, and vision insurance as well as life and disability
- Retirement savings plan with company match
- Generous time off/vacation
- Professional development opportunities
- Flexible work environment
Telecommuting Requirements
- This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas.
- Must live in the United States within the CST or EST time zones.
- Company business hours are weekdays 9-5 CST.
- Required to have a dedicated work area established that is separate from other living areas and provides information privacy.
- Ability to keep all company sensitive documents secure.
- Must live in a location that receives an existing high-speed internet connection/service.
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