Medical Claims Processor

Location: Tucson, AZ
Date Posted: 03-30-2018
Medical Claims Processor – Managed Care
Tucson, AZ
** This is a Full Time, Benefits Available, CONTRACT opportunity, expected to last 6 months, or longer! ** 

Job Summary:
The Claims Examiner is responsible for in-depth analysis and final resolution of claims requiring clinical review, ensuring full compliance with policies and all regulatory procedures along with building, and fostering collaborative working relationships.  The Claims Examiner is also responsible for reviewing medical claims and documentation, using good judgment to make decisions regarding appropriate payment practices and communicating decisions.  This position specifically serves as the internal claims payment expert trainer, and as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues.
Position Description: 
  • Serve as the internal claims payment expert, and as a liaison between the plan, claims, providers and various departments to effectively identify and resolve claims issues.
  • Review claims for medical necessity, coding and assure payment per the terms of the contract, member benefits and authorization.
  • Research and resolve complex verbal and written providers’ claims inquiries
  • Provide technical review of claims and medical records including records submitted by providers and internal records provided in electronic healthcare data bases.
  • Identify providers experiencing a large number of claims issues or with the potential to develop claims issues and proactively work to eliminate barriers for accurate and timely claims processing.
  • Prepare both internal and external documentation, assuring clarity in communication to all stakeholders.
  • Meet with external and internal clients for reviewing decisions and improving processes for better documentation and communication.
  • Direct and educate provider services and provider relations staff with the claims reprocessing notification, utilizing knowledge of provider billing and claims processing.
  • Identify needs and conduct additional claims training to internal departments.
  • Apply knowledge of medical bill analysis relating to state and federal regulations affecting medical billing practice.
  • Review claims to identify any potential third party or workers’ compensation liability and inform management.
  • Communicate with appropriate internal staff when identifying questionable billing practices or third party collection opportunities.
  • Performs data analysis and trending to improve departmental quality.
  • Provides trend analysis and review of errors, outputs and solutions to leadership using information from provider disputes.
  • Administer the contractual compliance of claims workflow through the entire claim life cycle to ensure timely processing to ensure compliance with all regulatory agencies.
Background Profile:
Requires graduate of high school or equivalent education; Associate degree preferred.
At least 3-4 years direct experience as a claims processor / claims reviewer /physician biller in a payer setting.
Around 2-3 years of experience working at a Managed Care Organization (Health Plan, HMO, MSO/TPA, IPA, Medical Group, etc).
Requires knowledge of and working experience with ICD-9 / ICD-10, CPT and HCPC coding systems.
Strong qualitative and quantitative skills, including but not limited to healthcare, finance and operational data, as well as the use of analytical tools
Strong analytical mind, with problem solving skills, an aptitude for accuracy, and attention to detail.
Ability to interpret, analyze and summarize large data sets and develop professional reports.
Excellent verbal and written communication skills, as well as excellent critical thinking skills.
Ability to present information logically and is able to assist others understand the information.
Strong skills presenting complex data and outcomes to executive teams; presentation software experience and samples will be expected during the hiring/interview process.
Knowledge of contracts and contractual interpretations for payment and benefit issues.
Knowledge of medical terminology, healthcare coding conventions and industry standard payment methodologies.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Advanced computer skills required, to include Microsoft Word, Excel, Power Point, Access, and advanced data entry.
480.425.2451 (CALL – TEXT – FAX)
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