Medicare Claims Processor

We need to output HTML fragment with headings

for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title as heading. Remove boilerplate like welcome, apply button, etc. Keep substantive info: description of role, reporting line, mission, experience needed, minimum qualifications, preferred qualifications, core duties, physical requirements, working environment, skills and abilities, scheduled weekly hours, exempt/non-exempt, shift, company, cost center maybe. We need to decide sections: About the role (intro paragraph), Responsibilities (core duties), Requirements (minimum qualifications?), Qualifications (preferred qualifications?), Skills (skills and abilities), Benefits (none given), Pay (none), Schedule (scheduled weekly hours, shift, exempt/non-exempt). Since Benefits, Pay not present, we omit those sections. We must not include placeholder text like "commensurate with experience". Not present. We need to use

• for any list of duties/requirements/benefits. So for responsibilities list, we should use
  • . For minimum qualifications list, maybe also list. For preferred qualifications list. For skills list. We need to preserve all substantive info, not invent or summarize away detail. So we need to include all details from the posting. Let's extract content: Intro paragraph: "Come join our Peak Health team at WVU Medicine as a Medicare Insurance Claims Processer, contributing to the foundation for an innovative, new health plan. This position will report to the Medicare Claims Supervisor, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team reviews and oversees the adjudication of claims ranging from simple data entry to complex specialty claim research. The Medicare Claims team analyzes and processes insurance claims, checking for validity in accordance with all CMS guidelines. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluates online entry, error correction, and quality control for final adjudication of paper/electronic claims." That's the About the role. Minimum Qualifications: - EDUCATION, CERTIFICATION, AND/OR LICENSURE: Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience - EXPERIENCE: One (1) year of Medicare claims processing experience - One (1) year of experience working with CMS/professional and UB/institutional claims - One (1) year of customer service experience Preferred Qualifications: - EDUCATION, CERTIFICATION, AND/OR LICENSURE: Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience - EXPERIENCE: Three (3) years of Medicare claims processing experience - Three (3) plus years of medical or institutional claims processing and customer service experience - Experience in Medicare medical insurance and Medicare supplement preferred - Familiarity navigating the EPIC software programs Core Duties and Responsibilities (list): - Ensure accuracy of data entered and record maintenance - Analyze claims to determine the extent of insurance carrier liability - Resolve claim edits, review history records, and determine benefit eligibility for service - Review payment levels to arrive at final payment determination - Interpret contract benefits and adjudicate claims in accordance with the specific Medicare claims processing guidelines - Meet all production and quality standards, maintaining Work queues according to department standards - Effectively communicate with internal and external colleagues - Elevate issues to next level of supervision, as appropriate - Attend all required training classes, demonstrating proficiency and the ability to learn - Read and interpret explanation of benefits (EOBs) - Provide mentorship to less experienced staff as deemed necessary and assigned by leadership - Other duties as deemed appropriate by the Claims Supervisor/Manager - Maintain strict confidentially of patient/member as specified under PHI and HIPAA guidelines Physical Requirements: - Ability to sit for extended periods of time - Comfortable working at times with limited social interaction Working Environment: - Standard/hybrid/remote office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.) - Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access, MS Teams) - Internet Explorer and EPIC Skills and Abilities: - Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records. - Ability to take direction and to navigate through multiple systems simultaneously. - Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette. - Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction. - Ability to use mathematics to adjudicate claims. - Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services. - Knowledge and understanding of medical terminology, third party payors and insurance preferred. - Requires attention to detail, the ability to be organized, ability to work independently, ability to apply critical thinking, time management and to be able to perform multiple tasks simultaneously. - Maintain an open, a positive and a collaborative perspective with internal and external colleagues and leadership. - Working knowledge of Medicare medical insurance terminology, procedure, diagnosis codes and HIPPA requirements. Additional Job Description: - Scheduled Weekly Hours: 40 - Exempt/Non-Exempt: Shift: United States of America (Non-Exempt) - Company: PHH Peak Health Holdings - Cost Center: 2902 PHH Claims Operations We need to decide sections: About the role (intro), Responsibilities (core duties), Requirements (minimum qualifications), Qualifications (preferred qualifications), Skills (skills and abilities), Schedule (scheduled weekly hours, exempt/non-exempt, shift, company, cost center maybe). Could also include Physical Requirements and Working Environment as part of Responsibilities or separate? The instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It suggests we can have those specific headings. It didn't list Physical Requirements or Working Environment as headings, but we could incorporate them under Responsibilities or Skills? Probably better to include them under Responsibilities (as part of job description) or maybe under a separate heading like "Working Conditions" but not allowed. Since only those headings are suggested, we should stick to them. However we must preserve all substantive info; we can include physical requirements and working environment within the Responsibilities section as part of the description (maybe as a list). Or we could create a separate section but not using those headings would violate instruction? The instruction says: "Use

    for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It gives examples, not an exhaustive list; we could use other headings if needed, but they say "e.g." So we could add other headings if needed. But they also say "Prefer a few substantive sections over many thin ones." So maybe we incorporate physical requirements and working environment into Responsibilities or Skills. Better to have sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Schedule. That covers all. Now we need to format. About the role:

    with the intro paragraph. Responsibilities:

    Responsibilities

    then
    • each duty. Requirements:

      Requirements

      then
      • each minimum qualification item. Qualifications:

        Qualifications

        then
        • each preferred qualification item. Skills:

          Skills

          then
          • each skill/ability item. Schedule:

            Schedule

            then

            with scheduled weekly hours, exempt/non-exempt, shift, company, cost center maybe as a list? Could be

            • but it's not a list of duties; but we can use

              with details separated by commas or semicolons. The instruction: Use

              • for any list of duties/requirements/benefits, and

                for prose. So schedule is not a list of duties/requirements/benefits, so we can use

                . We'll include the details. We must not repeat job title as heading. Already not. We must not include Job ID/requisition numbers as headings; none present. We must remove boilerplate: welcome, apply button, etc. Already omitted. Now produce HTML fragment. Let's craft. About the role paragraph: combine sentences. "Come join our Peak Health team at WVU Medicine as a Medicare Insurance Claims Processor, contributing to the foundation for an innovative, new health plan. This position will report to the Medicare Claims Supervisor, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team reviews and oversees the adjudication of claims ranging from simple data entry to complex specialty claim research. The Medicare Claims team analyzes and processes insurance claims, checking for validity in accordance with all CMS guidelines. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluates online entry, error correction, and quality control for final adjudication of paper/electronic claims." Note: The posting says "Medicare Insurance Claims Processer" (typo). We'll keep as given? Probably keep exact wording: "Medicare Insurance Claims Processer". We'll preserve. Now Responsibilities list items: copy each bullet. List: - Ensure accuracy of data entered and record maintenance - Analyze claims to determine the extent of insurance carrier liability - Resolve claim edits, review history records, and determine benefit eligibility for service - Review payment levels to arrive at final payment determination - Interpret contract benefits and adjudicate claims in accordance with the specific Medicare claims processing guidelines - Meet all production and quality standards, maintaining Work queues according to department standards - Effectively communicate with internal and external colleagues - Elevate issues to next level of supervision, as appropriate - Attend all required training classes, demonstrating proficiency and the ability to learn - Read and interpret explanation of benefits (EOBs) - Provide mentorship to less experienced staff as deemed necessary and assigned by leadership - Other duties as deemed appropriate by the Claims Supervisor/Manager - Maintain strict confidentially of patient/member as specified under PHI and HIPAA guidelines Note spelling: "confidentially" maybe typo but preserve. Now Requirements list (minimum qualifications): - Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience - One (1) year of Medicare claims processing experience - One (1) year of experience working with CMS/professional and UB/institutional claims - One (1) year of customer service experience Now Qualifications list (preferred): - Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience - Three (3) years of Medicare claims processing experience - Three (3) plus years of medical or institutional claims processing and customer service experience - Experience in Medicare medical insurance and Medicare supplement preferred - Familiarity navigating the EPIC software programs Now Skills list: - Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records. - Ability to take direction and to navigate through multiple systems simultaneously. - Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette. - Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction. - Ability to use mathematics to adjudicate claims. - Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services. - Knowledge and understanding of medical terminology, third party payors and insurance preferred. - Requires attention to detail, the ability