Clinical Editing Dispute Review Associate

W3R Consulting; City of Rochester (NY); Presencial; USD 60.000 - 90.000; Jornada completa

Descripción de la vacante

W3R Consulting seeks a detail-oriented professional to triage, research, and resolve clinical editing inquiries across programs. You will coordinate with Medical Directors, Health Plans, and providers to ensure timely resolution and accurate communications.

Responsibilities include logging and tracking inquiries, producing reports, and supporting appeals functions while applying knowledge of coding conventions and claims processing systems.

Formación

• Bachelor's degree with a minimum of three years in claims operations or customer service.
• CPC certification desired; enrollment in CPC class within one year of hire.
• Proficiency with spreadsheets, databases, word processing and coding software products.
• Experience with health reimbursement methodologies and coding conventions (Medicare/Medicaid, DRG, CPT, HCPC, ICD9).
• Familiarity with claims processing systems (CAPS/UWIN, LRSP, TOPPS, FACETS).

Responsabilidades

• Triages inquiries by obtaining information from appropriate Medical Directors and staff.
• Assigns, tracks and resolves clinical editing inquiries; maintains logs and databases.
• Composes and emails communications for approved/denied inquiries; communicates results to providers.
• Monitors timelines for inquiry review, adjudication and response.
• Enters claim information in remarks screen indicating inquiry or appeal status.
• Contacts provider offices to obtain correct claim/ordering information.
• Develops and prepares metrics to monitor inquiries and functions weekly.

Conocimientos

Claims operations

Customer service

Problem solving

Communication

Educación

Bachelor's degree

Herramientas

ClaimCheck

CCI

Coding software

Descripción del empleo

W3R Consulting seeks a detail-oriented professional to triage, research, and resolve clinical editing inquiries across programs. You will coordinate with Medical Directors, Health Plans, and providers to ensure timely resolution and accurate communications.

Responsibilities include logging and tracking inquiries, producing reports, and supporting appeals functions while applying knowledge of coding conventions and claims processing systems.