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

• Direct

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

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