Job Description

Job Description

Job Description

OBJECTIVE:

We are looking for a skilled and detail-focused Medical Claims Reviewer to perform comprehensive reviews of medical, surgical, and Medical health claims for inpatient and outpatient services. This role involves using your clinical expertise, coding proficiency, and claims processing knowledge to assess and approve claims accurately and efficiently. You will ensure claims are aligned with program benefits and assist various stakeholders by providing coding-related insights and resolving inquiries related to claims processes.

ESSENTIAL DUTIES AND RESPPONSIBILITIES:

• Review and evaluate medical and surgical claims retrospectively for both inpatient and outpatient care.
• Utilize clinical knowledge and coding standards to validate claims and ensure accurate processing.
• Gather and prepare the necessary documentation for case payments and approvals.
• Verify adherence to program guidelines, benefits, and authorizations.
• Data entry of claims
• Collaborate with medical directors, peer reviewers, Claims Administration, and other departments to share relevant clinical and coding information.
• Act as a resource for staff on claims-related questions.
• Monitor pending claims to ensure unnecessary delays are avoided.
• Identify and report system issues, test and troubleshoot system configuration, complete assigned reports, and run other system tasks or reports assigned
• Other job tasks as necessary

COMPETENCIES:

• Comprehensive understanding of medical and institutional claims workflows.
• Strong grasp of medical coding practices and claims evaluation processes.
• High attention to detail with strong analytical and critical-thinking skills.
• Effective communication skills and the ability to work across teams.
• Proficiency in claims review software and related tools.
• Microsoft Suite knowledge; Proficiency in Excel.

EDUCATION AND EXPERIENCE REQUIRED:

• Minimum HS diploma, college degree desired but not required
• At least 2 years of experience reviewing medical claims.
• Allscripts or Modmed experience a plus

WORKING CONDITIONS/PHYSICAL DEMANDS:

• Must be able to sit and work at a computer for extended periods of time
• Requires manual finger dexterity and vision corrected to normal range
• Must be able to lift 25 lbs

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