Title: Claims Reviewer
Location: Remote
Pay rate: $28 an hour
Duration: 03-06 months contract position
Shift: Mon to Fri 8 am to 5 pm AZ time zone
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.
Education & Experience Required:
Preferred:
Key Responsibilities:
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, Intranet, 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
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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