Medical Claims Specialist - CEDENT

Los Angeles, CA

Required:

Ability to operate PC-based software programs or automated database management systems.
Strong communication skills with excellent analytical and problem solving skills. Ability to self-manage in a fast-paced, detail-oriented environment.
Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (PDR, CPT, ICD-10, and HCPCS), and complete product and Coordination Of Benefits (COB) knowledge.
Moderate knowledge of Microsoft Word and Excel.

Duties

Process incoming claims: Determine correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions;
Process all claims eligible Or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner;
Document provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims; Identify dual coverage, Potential third party savings/recovery;
Maintain department databases used for report production and tracking on-going work;
Claims will be processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)
Perform special projects and ad-hoc reporting as necessary. Projects will be complete and reports will be generated within the specific time frame agreed upon at the time of assignment. (15%)
Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)
Work with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%) Attend meetings as required. Claims Department/Operations Division will be represented at internal and external meetings. (5%)
Perform other duties as assigned. (10%)

Education Required

Education Preferred

Source : CEDENT