Medical Claims Representative

About the role

The Medical Claims Representative works under minimal supervision adjudicating complex and specialty claims. They release designated pending claims to achieve established production, quality, and cycle time standards in accordance with EOC, Benefit Schedules and contractual arrangements. They monitor and report desk inventory notifying management of problem identification. This role is primarily focused on claims analysis and adjudication and does not include inbound or outbound customer service phone responsibilities.

Responsibilities

• Adjudicate claims in accordance with established quality and production standards
• Monitor work inventory and submits required reports accurately and by established deadlines
• Analyze medical claims to ensure accurate adjudication in accordance with Evidence of Coverage (EOC) documents, Benefit Schedules, and Provider Contracts
• Release claims within established timeframes to meet company requirements, state regulations, contractual obligations, and performance standards
• Identify processing issues and reports findings to management
• Resolve priority projects and complex assignments
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company, and departmental confidentiality guidelines

Requirements

• High School Diploma / GED OR equivalent years of work experience
• Must be 18 years of age or older
• 1+ years of medical claims processing experience in working with HMO / PPO or indemnity claims
• 1+ years of experience with Medical terminology, ICD-10, or CPT coding with an understanding of Insurance Certificates, Benefit Schedules, Provider / Group Contracts and Standard Insurance Industry Practices
• Willingness to interview onsite at 2720 N. Tenaya Way, Las Vegas, NV, 89128
• Willingness to work onsite at 2720 N. Tenaya Way, Las Vegas, NV, 89128
• Ability to work full time (40 hours / week), Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6:00 am - 5:00 pm. Alternate schedules are available for those who would prefer to work four 10-hour shifts from Monday - Friday as long as employees are working the hours per business need. It may be necessary, given the business need, to work occasional overtime

Qualifications

• 2+ years of medical claims processing experience in working with HMO / PPO or indemnity claims
• 2+ years of experience with Medical terminology, ICD-10, or CPT coding with an understanding of Insurance Certificates, Benefit Schedules, Provider / Group Contracts and Standard Insurance Industry Practices
• 1+ years of experience in Medical / Dental insurance, office or medical billing setting

Skills

• Understanding of basis mathematics
• Capacity to learn and apply, applicable federal and state laws, regulations, policies, and industry guidelines related to healthcare claims processing and operational compliance
• Experience working in a high-volume production environment while consistently meeting established productivity and quality standards
• Demonstrated analytical reasoning, critical thinking, and problem-solving skills
• Adaptability to change and flexibility are key to success in the role, along with the ability to maintain a positive work ethic

Benefits

• Highest competitive base pay
• Full and comprehensive benefit program
• Performance rewards
• Management team who demonstrates their commitment to your success
• 18 days of Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life & AD&D Insurance along with Short-Term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement - up to $5,250 per calendar year for job-related coursework
• Adoption Assistance Plan
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

Pay

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Schedule

This position is full time (40 hours / week), Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 6:00 am - 5:00 pm. Alternate schedules are available for those who would prefer to work four 10-hour shifts from Monday - Friday as long as employees are working the hours per business need. It may be necessary, given the business need, to work occasional overtime.