Hospital Claims Processor V

1199seiu; New York (NY); On-site; USD 42,000 - 65,000; Full time

Job summary

1199SEIU is seeking a healthcare claims processor to review hospital claims, determine actions to resolve pended items, and process claims using the QNXT system.

You will validate data, ensure eligibility and benefits coverage, apply pre-authorization rules and contractual policies, and respond to provider inquiries while maintaining accuracy and timeliness in a fast-paced environment.

Qualifications

• High School Diploma or GED required; some college preferred.
• Minimum two years experience entering and updating hospital/medical claims.
• Basic keyboarding skills.
• Knowledge of ICD-9/ICD-10 and CPT codes; familiarity with hospital claims processing.

Responsibilities

• Review hospital claims and determine action needed to resolve pended claims.
• Process and evaluate hospital claims manually or through claims workflow.
• Validate information entered in hospital claims module (QNXT); determine the workflow needed to resolve discrepancies.
• Finalize hospital claims by applying eligibility, benefits, pre-authorization rules, and policies.
• Respond to call tracking tickets from providers in a timely manner.
• Perform additional duties and special projects as assigned by management.

Skills

Analytical skills

Organizational skills

Team collaboration

Deadline-driven

Education

High School Diploma or GED

Tools

QNXT system

Job description

Responsibilities

• Review hospital claims and determine action needed to resolve pended claims
• Process and evaluate hospital claims manually or through claims work flow
• Validate information entered in hospital claims module (QNXT); determine the process or work flow needed to resolve discrepancies
• Finalize hospital claims by applying knowledge of eligibility, benefits, pre-authorization rules, contractual policy and operational procedures
• Review, finalize and respond to call tracking tickets in a timely manner to provider inquires
• Perform additional duties and special projects as assigned by management

Qualifications

• High School Diploma or GED required, some College or Degree preferred
• Minimum two (2) years experience entering and updating hospital or medical claims in a health insurance or benefits environment required
• Basic keyboarding skills required
• Strong knowledge of hospital claims, eligibility, benefits, and reauthorization rules; knowledge of health claims system (QNXT)
• Good knowledge of International Classification of Diseases (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes
• Demonstrated organizational, perform multiple priorities, and analytical skills with the ability to follow through on assignments
• Able to work well independently and in a team environment
• Ability to meet strict deadlines, work well under pressure and in a fast-paced environment
• Must meet performance standards including attendance and punctuality