Claims Processor
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Position:
Claims Processor Position
Summary:
Performs decision making for paper and electronically submitted complex claims issues, complex claims reports, complex claims issues and processing, complex claim adjustments & complex claims related activities.
Must be knowledgeable in all operational processes and communicate issues clearly.
Must be able to service accurately any plan under the Essence name & apply market specifics when applicable.
Is the point of contact for members, providers and other health care professionals by answering any questions pertaining to Medicare Advantage plans & the operation.
Must thoroughly investigate & document to the point of resolution all customer service issues.
Makes outbound calls as needed and responds to Second level of complexity correspondence.
Job Description:
Role and Responsibilities Answers inbound calls and make outbound calls from members regarding basic benefits and pharmacy questions, providers regarding claim payment questions or issues.
Customer Service oriented.
Handles challenging situations and acts urgently when necessary following IOD requirements.
Ability to follow changing instructions Ability to interact with other department's ie Enrollment, UM in resolving issues.
Research and Resolve adjustment inquires routed from customer service through the adjustment bucket queue.
Performs edit resolution from pended paper and electronic claims using decision-making skills for accurate claims processing.
Works complicated reports, which involves decision making on adjustments, overrides of copayments, coinsurance, correct pricing and provider selection.
Ability to research complex claims issues.
Electronic and Paper Corrected Claims, side by side comparison and correction in facets.
Handles challenging situations and acts urgently when necessary to perform adjustments timely.
Issues form letters & forms, when appropriate.
Performs initial overpayment recoupment process in the overpayment application.
Investigates and responds to paper correspondence within call logs which may result in a variety of additional actions within a timely manner.
Understands complicated pricing calculations for medical and hospital claims processing Advanced knowledge of Medicare fee schedules Good Understanding of Federal & State Healthcare regulations Good Understanding of Medicare Regulations, Rules and processing guidelines Medical Configuration of benefits and how they are administered.
Ability to process par and non par provider claims Specialized transplant pricing Manual pricing for COB and Hospice claims.
Manual pricing of professional and facility claims.
Critical Thinking Skills Knowledge of coordination of benefits processes IDN letter processing Direct Keyed Claims Experience, Qualifications, and Education High school diploma or general education degree (GED); or six to twelve months related experience and/or training; or equivalent combination of education and experience in Claim Processing.
Required 2 to 3 years claims processing experience.
Candidate must have working PC knowledge, 10-key capabilities, excellent keyboarding skills, and understanding of claim forms, CPT codes, HCPCS, and ICD-9.
Prior Claim processing experience in the healthcare field.
Prior experience in Customer Service is Preferred.
Healthcare/Medical/Medicare background.
Lumeris is an EEO/AA employer M/F/V/D.
Location:
Addison, TX, Addison, TX, Ann Arbor, MI, Apollo Beach, FL, Arlington, TX, Atlanta, GA, Austin, TX, Baltimore, MD, Barrow, GA, Bartow, FL, Baton Rouge, LA, Boston, MA, Brandon, FL, Braselton, GA, Carson City, NV, Charlotte, NC, Chicago, IL, Clearwater, FL, Columbus, OH, Dade City, FL, Dallas, TX, Dayton, OH, Denver, CO, Detroit, MI, Durham, NC
39 more Time Type:
Full time.
Estimated Salary: $20 to $28 per hour based on qualifications.
This account will allow you to receive notifications each step of the way through the job application process.
With these updates, you'll never have to wonder where you are in the process.
Additionally, we can easily send pertinent documents to you for your review.
Once you create the account, you may apply to any position you feel is a good fit without having to re-enter information.
Thank you for your interest in Lumeris.
Position:
Claims Processor Position
Summary:
Performs decision making for paper and electronically submitted complex claims issues, complex claims reports, complex claims issues and processing, complex claim adjustments & complex claims related activities.
Must be knowledgeable in all operational processes and communicate issues clearly.
Must be able to service accurately any plan under the Essence name & apply market specifics when applicable.
Is the point of contact for members, providers and other health care professionals by answering any questions pertaining to Medicare Advantage plans & the operation.
Must thoroughly investigate & document to the point of resolution all customer service issues.
Makes outbound calls as needed and responds to Second level of complexity correspondence.
Job Description:
Role and Responsibilities Answers inbound calls and make outbound calls from members regarding basic benefits and pharmacy questions, providers regarding claim payment questions or issues.
Customer Service oriented.
Handles challenging situations and acts urgently when necessary following IOD requirements.
Ability to follow changing instructions Ability to interact with other department's ie Enrollment, UM in resolving issues.
Research and Resolve adjustment inquires routed from customer service through the adjustment bucket queue.
Performs edit resolution from pended paper and electronic claims using decision-making skills for accurate claims processing.
Works complicated reports, which involves decision making on adjustments, overrides of copayments, coinsurance, correct pricing and provider selection.
Ability to research complex claims issues.
Electronic and Paper Corrected Claims, side by side comparison and correction in facets.
Handles challenging situations and acts urgently when necessary to perform adjustments timely.
Issues form letters & forms, when appropriate.
Performs initial overpayment recoupment process in the overpayment application.
Investigates and responds to paper correspondence within call logs which may result in a variety of additional actions within a timely manner.
Understands complicated pricing calculations for medical and hospital claims processing Advanced knowledge of Medicare fee schedules Good Understanding of Federal & State Healthcare regulations Good Understanding of Medicare Regulations, Rules and processing guidelines Medical Configuration of benefits and how they are administered.
Ability to process par and non par provider claims Specialized transplant pricing Manual pricing for COB and Hospice claims.
Manual pricing of professional and facility claims.
Critical Thinking Skills Knowledge of coordination of benefits processes IDN letter processing Direct Keyed Claims Experience, Qualifications, and Education High school diploma or general education degree (GED); or six to twelve months related experience and/or training; or equivalent combination of education and experience in Claim Processing.
Required 2 to 3 years claims processing experience.
Candidate must have working PC knowledge, 10-key capabilities, excellent keyboarding skills, and understanding of claim forms, CPT codes, HCPCS, and ICD-9.
Prior Claim processing experience in the healthcare field.
Prior experience in Customer Service is Preferred.
Healthcare/Medical/Medicare background.
Lumeris is an EEO/AA employer M/F/V/D.
Location:
Addison, TX, Addison, TX, Ann Arbor, MI, Apollo Beach, FL, Arlington, TX, Atlanta, GA, Austin, TX, Baltimore, MD, Barrow, GA, Bartow, FL, Baton Rouge, LA, Boston, MA, Brandon, FL, Braselton, GA, Carson City, NV, Charlotte, NC, Chicago, IL, Clearwater, FL, Columbus, OH, Dade City, FL, Dallas, TX, Dayton, OH, Denver, CO, Detroit, MI, Durham, NC
39 more Time Type:
Full time.
Estimated Salary: $20 to $28 per hour based on qualifications.
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