Processor IV

Responsibilities:

• Review suspense reason of medical claims and determine actions to be taken to handle edit
• Verify information entered in Medical claims system (QNXT) is correct, including patient's name, provider tax identification number and suffix, diagnosis and procedure codes
• Access medical claim image and other reference materials as appropriate
• Apply contractual benefits, medical policy, and operational procedures to finalize claim
• Handle adjustments and reversals of previously paid medical claims as necessary
• Review and handle call tracking tickets as assigned
• Research eligibility issues in Vitech (V3)
• Review and handle EOBs as assigned
• Research and complete request refund form
• Complete medical inquiry form for Medical Consultant
• Handle complex edits and manual pricing
• Perform additional duties and projects as assigned by management

Qualifications:

• High School Diploma or GED required, some college or degree preferred
• Minimum of two (2) years' experience examining and resolving medical claims in a health insurance or benefits environment required
• Thorough knowledge of medical claims processing including major medical, office visits, surgery, anesthesia, lab and x-rays required
• Knowledge of eligibility systems including Coordination of Benefits (COB) and Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits required
• Excellent data entry skills rate required
• Excellent oral and written communication skills
• Demonstrated organizational skills with ability to multi-task and follow up
• Good problem-solving skills with ability to work independently and as a team player
• Ability to work independently and as a team player
• Must meet performance standards including attendance and punctuality