Claims & Referral Processor

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Description: Title: Claims & Referral Processor II

Location: Aurora, Colorado

Duration: 6 Months c2h

Adjudicates medical claims/bills for payment or denial within contract agreement or guidelines/protocol, using knowledge of medical claim/bill payment processing and medical regulations, verifies and updates relevant data into computerized systems and calculates manually any adjustments needed. Verifies member eligibility and/or Medicare status. Receives daily workflow via Doc-Flo, and incoming phone calls. Interacts with members regarding claims/bills and resolves issues in a courteous and timely manner. Member focus: Making members/patients and their needs a primary focus of one's actions; developing and sustaining productive member/patient relationships. Actively seeks information to understand member/patient circumstances, problems, expectations, and needs. Builds rapport and cooperative relationship with members/patients. Considers how actions or plans will affect members; responds quickly to meet member/patient needs and resolves problems.

Essential Functions:

Receives, and adjudicates medical claims/bills for processing; reviews scanned, EDI, or manual documents for pertinent data on claim/bill for complete and/or accurate information (eg.date of service, provider number s, charged amounts, medical procedure codes, fee codes, etc.).

Researches claims/bills for appropriate support documents and/or documentation. Analyzes and adjusts data, determines appropriate codes, fees and ensures timely filing and contract rates are applied.

Ensures claims/bills meet eligibility, benefit and Medicare requirements. Processes hot provider files within time line. Identifies multiple service, multiple rates and completes claims/bills, pends, voids, refunds, and/or approves for payments.

Processes claims/bills as split claims when appropriate. Forwards complete claims/bills requiring additional authorization to appropriate personnel for approval or denial. Pends claims and receives pend claims for various types of research follow-up amongst other staff members.

Receives calls from members and/or tracks on-line communications, providers, explains reason(s) claims/bills have been denied or pending, by utilizing benefit plan agreement, eligibility, possible coordination of benefits, worker s compensation and policies and procedures. Explains the appeal process if necessary.

Provides one on one customer service in obtaining and providing information to the member and/or provider. Documents and tracks on-line communications.

Responds to and researches vendor and member problems, questions and complaints using on-line systems.

Provides training as assigned to new employees as well as cross training in all phases of claim and referral department processes.

Performs additional assignments such as, special projects related to the claims & referral department.

In addition to defined technical requirements, accountable for consistently demonstrating excellent service behaviors and principles defined by specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.

Basic Qualifications:

Experience

Four (4) years of claims payment experience required.

Experience must be on an automated system, including preparation of payments for medical bills, using medical terminology, CPT, ICD-9 and UB92 coding for both Medicare and non-Medicare claims, and working knowledge of other insurance benefit plans including coordination of benefits, no-fault and workers compensation. May substitute two (2) years of education for two (2) years of experience.

Education

High School graduation or equivalent.

License, Certification, Registration :N/A.

Additional Requirements:

Working knowledge of medical terminology required.

Effective communication skills required, including telephone work.

Personal computer terminal skills.

Demonstrates customer service skills, customer focus abilities and the ability to understand customer needs

Preferred Qualifications:

Personal computer terminal skills; windows based preferred.

There is very high potential for conversion to FTE on this position.

Zishan Khan

408 598 3037