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Medicare Claims Representative II

Medicare Claims Representative II

Job Description

The Medicare Claims Representative II is responsible for the processing of UB-04 facility and CMS-1500 professional claims for the full risk Medicare Advantage health plans with an emphasis on Medicare Prospective Payment Systems (e.g. DRG, RUG, APC). Position will also be responsible for utilization of Medicare PPS pricing tool to determine appropriate reimbursement.  Additional responsibilities include sending letters to providers or members to request additional information as needed or to request overpayments.

  • Interpret medical policy as it relates to claim payment at the direction of the Claims Supervisor or Claims Manager. Understand and interpret medical policy established by the Brown & Toland Medical Group. 
  •  Extensive knowledge with processing CMS-1500 professional and UB-04 facility claims with a focus on Medicare payment policies and methodology (e.g. DRG).  Knowledge of ADA claim form.
  •  Meet established hourly, weekly and monthly quality and production standards. 
  •  Process all types of medical claims with a thorough understanding of Brown & Toland claims adjudication policies and procedures (physician, hospital, vendor and ancillary providers) and the ability to manage EVR and pending reports. 
  •  Review and process claim adjustments.
  •  Review, interpret and apply the correct Medical Service Referrals/Authorizations.  Utilize appropriate reference materials to research information, to process claims accurately.  
  •  Acknowledge and understand all information discussed at staff meetings and fully comprehend updates and in-service training. 
  • Responsible for monitoring and reviewing pended claims in order to stay within compliance guidelines. 

Job Requirements

  • Minimum of four years prior claims processing experience in an IPA or Health Plan related setting with a focus on Medicare payment policies and methodology (e.g. DRG)
  • Ability to exercise good judgment and handle a fast paced environment 
  • Knowledge of ICD 9/10 (International classification of diseases), CPT (Current Procedural Terminology) codes
  • Recent experience with inpatient hospital claims and claims processing based on Medicare policies and payment methodology (e.g. DRG)
  •  Ability to work independently, organize and prioritize work
  • Must be able to demonstrate the ability to make decisions, clarify policies and resolve claims issues
  • Ability to communicate and work well with internal and external customers
  • Have strong independent decision making skills and demonstrated ability to take initiative to resolve issues
  • Knowledge of ICD-9 Diagnostic Codes, CPT Procedure Coding, HCPC Codes
  • System experience is required
  • Thorough knowledge of medical terminology, enrollment and membership activities, and claims processing procedures/systems
  • Must have a High School Diploma or equivalent, some college desired

Job Snapshot

Employment Type Full-Time
Job Type Health Care
Education High School
Experience Not Specified
Manages Others Not Specified
Industry Healthcare - Health Services
Required Travel Not Specified
Job ID 1432
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Medicare Claims Representative II


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