Medicare Claims Processor - Peak
: Job Details :

Welcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position.Come join our Peak Health team at WVU Medicine as a Medicare Insurance Claims Processer, contributing to the foundation for an innovative, new health plan. This position will report to the Medicare Claims Supervisor, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team reviews and oversees the adjudication of claims ranging from simple data entry to complex specialty claim research. The Medicare Claims team analyzes and processes insurance claims, checking for validity in accordance with all CMS guidelines. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluates online entry, error correction, and quality control for final adjudication of paper/electronic claims.MINIMUM QUALIFICATIONS:EDUCATION, CERTIFICATION, AND/OR LICENSURE:1. Associate Degree in related healthcare field or high school diploma and 3 (three) years of healthcare claims billing and processing experienceEXPERIENCE:1. At least 1 (one ) year of Medicare claims processing experience2. At least 1 (one) year of experience working with CMS/professional and UB/institutional claims3. At least 1 (one) year of customer service experience4. Working knowledge of Medicare medical insurance terminology, procedure, diagnosis codes and HIPPA requirementsPREFERRED QUALIFICATIONS:EDUCATION, CERTIFICATION, AND/OR LICENSURE:1. Bachelor's degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experienceEXPERIENCE:1. 3 (three) plus years of Medicare claims processing experience2. 3 (three) plus years of medical or institutional claims processing and customer service experience3. Experience in Medicare medical insurance and Medicare supplement preferred4. Familiarity navigating the EPIC software programsCORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.1. Ensure accuracy of data entered and record maintenance2. Analyze claims to determine the extent of insurance carrier liability3. Resolve claim edits, review history records, and determine benefit eligibility for service4. Review payment levels to arrive at final payment determination5. Interpret contract benefits and adjudicate claims in accordance with the specific Medicare claims processing guidelines6. Meet all production and quality standards, maintaining Work queues according to department standards7. Effectively communicate with internal and external colleagues8. Elevate issues to next level of supervision, as appropriate9. Attend all required training classes, demonstrating proficiency and the ability to learn10. Read and interpret explanation of benefits (EOBs)11. Provide mentorship to less experienced staff as deemed necessary and assigned by leadership12. Other duties as deemed appropriate by the Claims Supervisor/Manager13. Maintain strict confidentially of patient/member as specified under PHI and HIPAA guidelinesPHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.1. Ability to sit for extended periods of time2. Comfortable working at times with limited social interactionWORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.1. Standard/hybrid/remote office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access, MS Teams) Internet Explorer and EPICSKILLS AND ABILITIES:Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.Ability to take direction and to navigate through multiple systems simultaneously.Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette.Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.Ability to use mathematics to adjudicate claims.Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services.Knowledge and understanding of medical terminology, third party payors and insurance preferred.Requires attention to detail, the ability to be organized, ability to work independently, ability to apply critical thinking, time management and to be able to perform multiple tasks simultaneously.Maintain an open, a positive and a collaborative perspective with internal and external colleagues and leadership.Additional Job Description:Scheduled Weekly Hours:40Shift:Day (United States of America)Exempt/Non-Exempt:United States of America (Non-Exempt)Company:PHH Peak Health HoldingsCost Center:2902 PHH Claims Operations