DEPARTMENT: Claims/Customer ServiceMISSION: "TO PROVIDE INNOVATIVE MANAGED CARE SOLUTIONS FOR THE BENEFIT OF EVERYONE"REPORTS TO: Chief Operating OfficerFLSA STATUS: NON-EXEMPTPURPOSE
The ideal candidate will be responsible for processing medical and workers compensation claims, based on the preferredprovider’s contractual language while applying industry standards and practices and performing standard customerservice functions. The successful candidate must be able to interpret plan contract language and apply appropriatecontractual provisions with high quality while meeting production standards as defined by management
ESSENTIAL FUNCTIONS: Process complex claims for physician, hospital, and specialty areas with high degree of accuracy and productivity. Process adjustments, according to company policies and procedures. Respond timely to written appeals. Effective verbal and in written communication skills and provider related issues. Answer incoming calls from members, clients, and providers. Overtime, as required. Attend meetings. Other duties may be assigned by Management.
MANAGEMENT/SUPERVISORY RESPONSIBILITIESN/AQUALIFICATIONS, KNOWLEDGE & SKILLTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Therequirements listed below are representative of the knowledge, skill, and/or ability required. Reasonableaccommodations may be made to enable individuals with disabilities to perform the essential functions.Minimum Requirements:o Claims Processingo Customer Service Resolving and responding to claims and repricing appealsExcellent understanding ofo UB04 billing practices and codes including but not limited to Revenue, HCPCS, and MSDRG Codeso HCFA 1500 billing practices and codes including but not limited to CPT and HCPCS Codeso Medicare Modifier Rules Knowledge of medical terminology and coding rules. Computer proficiency and technical aptitude with the ability to utilize MS Office products. Highly organized and detail oriented.
Able to work and adjust priorities in a fast-paced environment. Must be willing to accept responsibility and to show good judgment, initiative, honesty, integrity andresourcefulness.EDUCATION High School Diploma or equivalent. Some college preferred. Minimum 3 years of experience Medical claims examining/processing Minimum 3 years of resolving appeals.
LANGUAGE SKILLSFluency in English spoken and writtenMATHEMATICAL SKILLSBasic Computational, Statistics & AnalyticsCERTIFICATE, LICENSES, REGISTRATIONSN/AEQUIPMENT USEDPersonal Computer (including peripherals such as printers, plotters, etc.), and other Multi-Use Computers (IncludingPeripherals Such As Printers, Plotters, Tape Drives Etc.), E-Mail, Calculator, Copier, Faxes, Telephone, ShredderPHYSICAL DEMANDS The physical demands described here are representative of those that must be met by anemployee to successfully perform the essential functions of this job. Reasonable accommodations may be made toenable individuals with disabilities to perform the essential functions.
Sight/Visual/Other Senses: Use sight to notice changing events in the work environment; use hearing to identify andunderstand the speech of people; use hearing to notice changing events in the work environment.WORK ENVIRONMENT The work environment characteristics described here are representative of those an employeeencounters while performing the essential functions of this job. Reasonable accommodations may be made to enableindividuals with disabilities to perform the essential functions.Control your work pace or schedule of activities within defined perimeters; makes a significant contribution to theorganization; works with others on common tasks or projects; perform the same mental activities over and over;perform the same physical activities over and over. Stress tolerance and flexibility with schedule. Responsibilitiessometimes require working evenings and weekends, sometimes with little advance notice.Evolutions Healthcare Systems is a privately owned Provider Network Development and Management Company, basedin New Port Richey, Florida for almost 30 years. It is a boutique organization specializing in relationship management(aka Customized Network Solutions) for self-funded plans, Hospital Systems, Employer Groups, and TPA’s nationwide forGroup Health, Workers Compensation (WC), and Medical Auto.We are seeking individuals who enjoy working independently within a team environment and want to be challenged.We offer industry competitive benefits in a relaxed work environment.
Interested parties may send their current resume and salary requirements to: HR@EHSppo.comMission: "To Provide Innovative Managed Care Solutions for the Benefit of Everyone"