Medical Claims Specialist II - DOE - $1,000.00 Sig-on Bonus(Non-remote)

Responsibilities

• Processes referrals and Medical / Transportation claims for beneficiaries authorized to receive health services from facilities and providers outside of ANTHC.
• Determined patient’s eligibility according to established policies and procedures.
• Reviews claims or bills to determine if referral is on file or if a purchase order needs to be issued.
• Verifies International Statistical Classification of Diseases (ICD), Current Procedural Terminology (CPT), and revenue codes to determine if diagnosis and treatment were authorized as part of the referral.
• Determines payable claims and submits purchase orders.
• Tracks and monitors claim processing, resolving outstanding claims.
• Verifies all identified insurance carriers for eligibility; confirms carrier policy.
• Reviews claims before submission to fiscal intermediary; assesses adjudicated claims.
• Identifies liability and guarantors; reviews and adjusts account balances; interprets Explanation of Benefits (EOBs); analyzes billing components on claim forms.
• Provides assistance to patients, carriers, and other external partners.
• Answers incoming phone calls and review incoming correspondence and materials, accurately interprets and communicates Medical Claims regulations, policies, and procedures to internal and external customers.
• Researches unauthorized claims, referral and claim status, and other customer inquiries in a timely, efficient, and appropriate manner to ensure customer satisfaction.
• Verify patient and insurance information according to established procedures; obtains alternate health resource information, including Medicaid, Medicare, private insurance, and other liability coverage, prior to authorizing referrals and issuing purchase orders.
• Provide alternate health resource information, including Medicare, Medicaid, and private insurance, to providers and facilities for patients referred by an ANMC physician.
• Assist in the decision making process regarding the information.
• Research claim status of provider claims with the Fiscal Intermediary.
• Reviews accounts with credit balances to determine whether an overpayment exists.
• Participates in payer recoupment, offset, payer refund request and voluntary refund process.
• Issues and explains letters of intent or denials (i.e. vacationer/mover, student enrollment,) to customers in a clear and concise manner and according to established standards and procedures under the student and traveler program.
• Maintains strong knowledge of referral and claim processing software, master files and interface conversion tables including data tracking of received medical claims.
• Prepares or assist in the preparation of month end reports through desk audit, pending claims reporting from fiscal intermediary, and aging PO’s clean up.
• Prioritizing Catastrophic Health Emergency Fund (CHEF) for priority claims processing and reimbursement, verifying medical records, explanation of benefits, alerts, and PO’s, including repricing or negotiating rates of medical claims for savings and discounts through Data Isight and Multi-plan Network.
• Attends weekly staff meeting by reporting updates workload and process including any appeals and suggestions of patients and providers issues.
• Prepare and maintain case files submitted for review and appeals to PRC Director and / or PRC Committee.

Qualifications

• A billing or coding certification and/or Associate’s degree in medical billing and coding, Business, Finance, Accounting, or related field.
• Progressively responsible accounting technician, medical billing, or related work experience may be substituted on a year-for-year basis for college education.
• Non-supervisory - Two (2) years of accounting, medical billing, insurance, medical claims care office or related experience.