Summary
Job Summary
Responsible for researching and resolving claim issues within designated turnaround times and quality standards. Leads and coordinates meetings with various departments to set priorities for claim projects and monitor timelines to ensure efficient progression. Spearhead proactive initiatives to identify and address trends in claim denials early. Plays a crucial role in writing and continually auditing work processes to comply with configuration requirements, state mandates, and benefits. Manages and processes claims for skilled nursing facilities, ensuring thorough and accurate adjudication.
Skills
1. Strong computer skills and proficient in Microsoft products (Excel, Word, PowerPoint,) and Crystal Reports.
2. Extreme attention to detail is required, in addition to strong planning and organizational skills.
3. Strong and effective verbal and written communication skills.
4. Ability to work both independently and in teams, while exhibiting exemplary interpersonal skills.
5. Proficiency in analytical assessment, critical thinking, and creative problem solving.
6. Able to evaluate effectiveness of processes.
7. Able to work under pressure and multi task.
8. Able to work both independently and as a member of the El Paso Health Team.
9. Knowledge of health plan systems and organizational relationships.
10. Able to accept and institute change.
Work Experience
Five years of work experience processing professional (CMS1500) and Institutional (UB04) claim types required. Knowledge of contract renewal, calculation of benefits for manually processed claims, attachment claims, complaint/appeals, and special claims projects. Knowledge of provider contracts and reimbursement interpretation, claims adjudication, and auditing experience. Experience with CPT-4, HCPCS, ICD-9, ICD-10, diagnostic coding required. Familiarity of the State of Texas local coding guidelines and Corrective Coding guidelines required.
License/Registration/Certification
Completion of a formal CPT Coding Certification and Insurance Processor program preferred.
Education and Training
High school diploma or equivalent required. Bachelor degree in Business, Health Sciences or related field preferred.