Job Description
Title: Claims Reviewer
Location: Phoenix AZ 85053 (REMOTE)
Duration: 6+ Months
Pay Range: $28.00/hr on W2
Shift: Mon Fri 8.00 AM 5 PM PST
Job Summary
- Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services, as it relates to claims inquiry, resolution, audit, and related functions.
- Applies clinical, coding, and processing knowledge to conduct review of claims.
- Validates and compiles information necessary to prepare cases for program payment.
- Ensures adherence to Government contract requirements.
- Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed.
- Advises clinical and non-clinical staff on claims and coding questions.
Government Reporting
Education & Experience
Required
- High School Diploma or GED
- U.S. Citizenship
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2 years of claims review experience.
- Knowledgeable in medical, institutional, and behavioral health claims processes
- Demonstrated ability to communicate effectively, both verbally and in writing
- Experience using MS Word, Excel, and Office
Preferred
- Government claims experience
- Claims coding certification or equivalent experience
- Intermediate proficiency with MS Office suite
Key Responsibilities
- Validates claim outcomes for accuracy and routes for adjustment, as necessary.
- Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.
- Validates claims submission details against systems data.
- Adheres to all desktop procedures for assigned function.
- Identifies and appropriately communicates processing discrepancies or trends.
- Reviews claim data for process improvements.
- Communicates effectively and professionally with internal and external partners.
- Consistently meets or exceeds individual performance expectations.
- Identifies and reports potential quality or fraud issues to per established procedures.
- Performs other duties as assigned.
- Regular and reliable attendance is required .
Competencies
Technical Skills
- Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology.
- Proficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care, Financing Administration Common Procedure Coding System, and American Dental coding.
- Ability to meet or exceed production standards in compliance with contract.
Team-Building / Team Player
- Influence the actions and opinions of others in a positive direction and build group commitment.
Organizational Skills
- Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
High Intensity Environment
- Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Coping / Flexibility
- Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Computer Literacy
- Ability to function in a multi-system Microsoft environment using Word, Outlook, the Internet, and department software applications.
Communication / People Skills
- Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Commitment to Task
- Ability to conform to established policies and procedures; exhibit high motivation.
Coaching / Training / Mentoring
- Actively foster actions required for desired business outcomes through ongoing constructive feedback.
Working Conditions
- Ability to cover any work shift
- Ability to work overtime, if needed
- Onsite: works within a standard office environment
- Remote: private and secure workspace and workstation with high-speed internet is required.
- Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone
Job Tags
Contract work, For subcontractor, Interim role, Shift work