Claims Examiner
National Association of Latino Healthcare Executives, Denver, CO, United States
May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://www.lmpartnership.org/local-contracts.
Job Summary
Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.
Essential Responsibilities
For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.
Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.
Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.
Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.
Other duties as assigned within department job functions.
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Job Summary
Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.
Essential Responsibilities
For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.
Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.
Proactively communicate with internal departments as appropriate to resolve claims issues promptly.
Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.
Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.
Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.
Other duties as assigned within department job functions.
#J-18808-Ljbffr