Medical Claims Specialist

Duties and Responsibilities:

• Maintain ownership and responsibility for assigned accounts.
• Maintain working knowledge of applicable health insurers’ internal claims, appeals, and retro-authorization timely filing deadlines and processes.
• Review clinical denials including but not limited to referral, pre-authorization, medical necessity, non-covered services, investigational/experimental and billing resulting in denials and/or delays in payment.
• Draft and submit the medical necessity determinations to the Health Plan/Medical Director based on the review of clinical documentation in accordance with Medicare, Medicaid, and third-party guidelines.
• Medical Necessity Reviews are based on Medicare guidelines, and health insurer-specific guidelines.
• Review retro-authorizations in accordance with health insurer requirements and follow insurer process guidelines
• Identify denial patterns with client to mitigate risk and minimize regulatory penalties
• Escalate potential risks to client, client partners and/or leadership

Additional Duties

• Adherence to all policies and procedures.
• Compliance with HIPAA regulations
• Report all breaches to Corporate Security
• Maintain security of all client-issued and client-issued credentials (e.g., usernames, passwords, access).
• Perform additional duties as assigned.

Requirements:

• Ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads
• Ability to troubleshoot basic IT problems
• Intermediate knowledge of Windows operating system
• Intermediate Microsoft Office Products, such as: Word, Excel, Outlook & PowerPoint skills
• Excellent -critical thinking/ clinical judgement; and problem-solving skills
• Knowledge of vendor/client relationships and organizational structure
• Ability to cross reference all mandatory guidelines that pertain to the case and/or payer source
• Strong verbal and written communication

Job Type: Full-time

Pay: $16.00 - $18.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Calling on Claims: 2 years (Preferred)

Work Location:

• One location

Work Remotely:

• No

Work Location: One location