What are the responsibilities and job description for the Medical Claims Processor I position at Detego Health?
REQUIRED: Medical Claims Processing and Adjudication Experience
The Medical Claims Processor I role is a multifaceted position for the research and processing of healthcare benefits claims for inpatient, outpatient facilities and professional services. This person will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical claims, as well as various types of invoices, based upon specific knowledge and application of each client’s customized plan(s)
Key Responsibilities:
- Analyze, review and adjudicate medical claims in our Healthvue360 and HRP systems
- Read, analyze, understand, and ensure compliance with clients’ customized plans
- Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto
- Independently review, analyze and make determinations of claims for: reasonableness of cost; unnecessary treatment by physician and hospitals; and fraud
- Review, analyze and add applicable notes in our Healthvue360 and HRP systems
- Review billed procedure and diagnosis codes on claims for billing irregularities
- Analyze claims for billing inconsistencies and medical necessity
- Authorize payment, partial payment or denial of claim based upon individual investigation and analysis
- Review Workflow Manager daily to document and release pended claims, if applicable
- Review Pend and Suspend claim reports to finalize all claim determinations timely
- Assist and support other Claim Specialists as needed and when requested
- Attend continuing education classes as required, including but not limited to HIPAA training
REQUIRED:
- 2 years in claims processing and claims adjudication
- Knowledge of medical terminology and CPT, HCPCS, and ICD-10 coding
- Experience in the insurance industry required
- Experience in a hospital setting preferred
- Strong typing and computer skill set required
Job Type: Full-time
Pay: $22.00 - $24.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- Dental insurance
- Flexible schedule
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- Monday to Friday
Work setting:
- Office
Work Location: In person
Salary : $22 - $24