Healthcare Claims Associate II - BPM

Responsible for the accurate processing and completion of medical claims based on defined claims guidelines and policies. The Associate can demonstrate proficiency in product lines applicable to the processing unit.

Responsibilities

Process new claims or modify existing claims according to the appropriate and applicable action. Analyze claims to determine the appropriate action and approve or deny claims for payment. Determine accurate payment criteria for clearing pending claims based on defined policies and procedures. Research claim edits to determine appropriate benefit application utilizing established criteria and apply physician contract pricing as needed for entry-level claims.

Review and address provider inquiries regarding claim adjudication. Understand and apply knowledge of medical coding (if applicable) and various medical claim forms to the claims process. Demonstrate the ability to work on a high volume of repetitive claims. Demonstrate increasing productivity to meet minimum requirements while maintaining quality standards.

Qualifications

Education

Credential or professional certification related to the current field of work is an advantage. Work Experience At least 2 years of medical claims processing experience. Experience in medical coding, including diagnosis coding and terminology, an advantage but not required Skillset Proficient knowledge of U.S. healthcare practices, medical coding (ICD-10, CPT-4, DRG, HCPCS), Clinical Documentation Improvement (CDI), medical terminologies, EDI, and HIPAA protocols.

Ability to multitask and follow documented claims processes with minimal supervision. Excellent verbal and written business communication skills. Strong proficiency in Windows OS and Microsoft Office applications, particularly Excel. Strong attention to detail and the ability to make appropriate decisions based on the information presented.