Summary: Researches and adjudicates medical claims to ensure that protocols are followed with regard to provider contracts, member benefit schedules, established guidelines, and departmental policies and procedures. Essential Duties and Responsibilities •Processes & adjudicates medical claims for accounts requiring multiple disciples in claims processing. • Validates claims information in the claims adjudication system •Reviews referral information for verification of services rendered. •Reviews eligibility for verification of member eligibility at time of service. • •Validates results of claims after completion of pre-processor, adjudication & claims pricing. •Corrects all system edits as a result of the 3 step claims process.
|Requisitos - Requirements
•Minimum of 3 years experience in a Medical Claims processing environment performing claims adjudication with varying levels of difficulty. •Prior claims adjudication experience with HMO, PPO, POS, Commercial, Medicare and Medicaid lines of business. •Prior claims experience processing PT/OT/ST/Physiatry claims •Demonstrated knowledge of ICD-10, CPT-4, HCPCS coding, and medical terminology. •High school diploma or equivalent. Bilingual required: Spanish/English