Mphasis
Location
Pune | India
Job description
Under the supervision of the Claims Manager, the Senior Claims Examiner is responsible for analyzing and processing claims and meeting defined quality and productivity standards.
Essential Functions:
Claims Processing
Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines
Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims
Accurately analyzes and interprets provider contracts
Researches claims and makes appropriate adjustments
System Testing
Assists with system configuration and testing for new clients
Assists with testing of new processes, and provides feedback
Reviews and tests fee schedules
Backup Coverage (as requested)
Reviews and approves batch close reports for examiners
Analyzes and authorizes high dollar claims
Determines appropriate payment for claims submitted for reconsideration (payment appeals)
Additional Functions:
Assists with training new or existing staff, as requested
Responds to clients inquiries related to claims processing
Communicates clearly and concisely, with sensitivity to the needs of others
Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards; will support the success of the entire team; establishes and maintains effective working relationships with co-workers
Follows all Policies and Procedures and HIPAA regulations
Maintains a safe working environment
Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
Establishes and maintains effective working relationships with co-workers
Participates in any required training sessions/seminars
Participates in special projects as requested
Supervisory Responsibility: None
Travel: Minimal travel, less than 10% is expected for this position. For remote positions, travel is required for initial training and for necessary, subsequent training. Travel may also be required for company events.
Knowledge, Skills and Abilities:
Education/Experience - Educational requirements include a high school diploma or equivalent. Five years of PACE plan management and/or claims processing knowledge required, along with current knowledge of Peak systems
Requires working knowledge of ICD-10, CPT, Revenue, and HCPCS coding, along with understanding of APC and DRG reimbursement
Requires knowledge of current computer technology, including the use of computers; knowledge and proficiency with associated software, including Excel and Word
Skilled in establishing and maintaining effective working relationships with co-workers and clients
Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency
Detail-oriented with ability to focus for extended periods
Ability to work independently, seeking supervision as needed
Ability to communicate professionally, clearly and effectively, verbally and in writing
Ability to meet attendance requirements to effectively fulfill all functions of the position
Ability to independently follow through on assigned tasks, without prompting
Ability to prioritize effectively and multitask
Physical Demands & Requirements :
Communicates by way of the telephone with participants, customers, vendors and staff
Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
Remains stationary for extended periods of time
Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects
Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy
Frequent, repetitive use of hands/fingers entering information on a keyboard
Occasional reaching to retrieve shelved items
Job tags
Salary
