Claims Examiner Senior Specialist

Talkpush; Quezon City; On-site; PHP 360,000 - 480,000; Full time

Job summary

Talkpush is seeking a Claims Analyst to review complex medical claims for accuracy and timely processing in line with contracts, regulations, health plan requirements, and internal policies. You will analyze professional and hospital claims, review authorization and provider contracts, perform follow-up tasks, and assist customer service with escalated member issues.

The role requires knowledge of health and managed care concepts, medical terminology, and coding schemes such as ICD-9-CM, CPT,

Qualifications

• 2-3 years claims experience in a managed care environment.
• 3-5 years UB-04 and professional claims processing.
• 3-5 years Medicare, Medicaid, Medical, PPO and HMO claims experience.

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.

Skills

Managed care concepts

Claims adjudication

Medical terminology

ICD-9-CM CPT HCPCS

Windows PC proficiency

Tools

Microsoft Windows

Job description

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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• General office equipment experience (i.e. photocopier, fax, calculator, ability to operate a PC and previous exposure to the Microsoft Windows environment).
• Must have an excellent understanding of health and managed care concepts and their application in the adjudication of claims.
• Strong working knowledge of ICD.9.CM, CPT, HCPCS, RBRVS coding schemes and medical terminology.

EXPERIENCE

• 2-3 years claims experience in a managed care environment.
• 3-5 years claims processing UB-04 and professional experience.
• 3-5 years Medicare, Medicaid, Medical, Commercial, PPO and HMO claims experience.