Hospital Claims Specialist: Efficient Resolution & Eligibility

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

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.