Medical Claims Processor

JOB SUMMARY

Responsible for the accurate and timely review of complex claims in accordance with applicable contracts, state and federal regulations, health plan requirements, policies and procedures, and generally accepted business practices.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Analyzes professional and hospital claims for accuracy according to set dollar thresholds and meets and maintains production and quality standards
• Reviews authorization and/or provider's contract and adjudicates claims accordingly.
• Perform any correspondence, follow-up and any projects delegated by claims supervisor.
• Provide assistance to the customer service department with escalated member issues.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reas...