Senior Medical Claims Processor

Health One Alliance, LLC; Dalton (GA); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

401K (4% Match)

Health Insurance

Dental Insurance

Vision Insurance

Paid Time Off

Life Insurance

Long Term Disability

Job summary

HealthOne Alliance, LLC currently seeks a Claims Processor II who will handle accurate and timely processing of professional and institutional medical claims in assigned Workflow roles. You will interpret benefit provisions and review claims to determine coverage based on contracts and guidelines, while meeting quality and productivity standards.

Key responsibilities include adjudicating claims up to specified limits, understanding provider contracts, and collaborating with leadership on complex

Qualifications

• High School Diploma or GED required.
• Associates or Bachelor's Degree preferred.
• At least one year experience in claims processing; professional and institutional processing.
• Knowledge of ICD-10, CPT4, DRG, HCPCS, medical terminology, EDI and HIPAA protocols preferred.
• Knowledge of UB and HCFA 1500 forms.
• Certified Professional Coder (CPC) preferred.
• Experience with Word and Excel.

Responsibilities

• Reviews and adjudicates claims up to specified dollar limits.
• Processes claims within performance guidelines of the department, including quality and timeliness.
• Works with and understands Company benefit plans.
• Understands provider contracts.
• Examines and interprets all relevant documents included with the claims.
• Responds to claim-specific questions, as applicable.
• Partners with leadership on any questionable claim activity.
• Understands logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.).
• Determines accurate payment criteria for clearing pended claims based on defined Policy and Procedures.
• Researches claim edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for claims.
• Works high volume of repetitive claims.
• Identifies claims with inaccurate data or claims that require review by appropriate team members.
• Contributes positively as a team player.
• Completes special projects as assigned and supports other Claims Department team members in assigned projects.
• Complies with all departmental and Company policies and procedures.
• Maintains regular and predictable attendance.
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice.
• Works to encourage and promote Company culture throughout the organization.

Skills

Claims processing

HIPAA compliance

Medical terminology

Data entry

Detail oriented

Education

Associate or Bachelor's Degree preferred

Tools

Word

Excel

Job description

HealthOne Alliance, LLC currently seeks a Claims Processor II who will handle accurate and timely processing of professional and institutional medical claims in assigned Workflow roles. You will interpret benefit provisions and review claims to determine coverage based on contracts and guidelines, while meeting quality and productivity standards.

Key responsibilities include adjudicating claims up to specified limits, understanding provider contracts, and collaborating with leadership on complex