Medical Claims Processor I

Job Summary
We are seeking a detail-oriented and knowledgeable Medical Claims Processor I to join our team. The Medical Claims Processor I role is a multi-faceted position for the research and processing of healthcare benefits claims for inpatient, outpatient facilities and professional services. This person will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical claims, as well as various types of invoices, based upon specific knowledge and application of each client’s customized plan(s). The Medical Claims Processor I will record and maintain insurance policies through the Plan Documents and claim information in the database systems and determine policy coverage while calculating claim amounts.

Responsibilities

• Analyze, review and adjudicate medical claims in our Healthvue360 and HRP systems
• Read, analyze, understand, and ensure compliance with clients’ customized plans
• Learn, adhere to, and apply all applicable privacy and security laws, including, but not limited to; HIPAA, HITECH and any regulations promulgated thereto
• Independently review, analyze and make determinations of claims for:

- reasonableness of cost;

- unnecessary treatment by physician and hospitals; and

- fraud

• Review, analyze and add applicable notes in our Healthvue360 and HRP systems
• Review billed procedure and diagnosis codes on claims for billing irregularities
• Analyze claims for billing inconsistencies and medical necessity
• Authorize payment, partial payment, or denial of claim based upon individual investigation and analysis
• Review workflow and release pended claims, if applicable
• Review, Pend, and Suspend claim reports to finalize all claim determinations timely
• Assist and support other Medical Claim Processors as needed and when requested by leadership
• Attend continuing education classes as required, including but not limited to HIPAA training
• Review stop loss and notification process
• Process claims with a proficiency of 98% or higher of production goals, based on benefit plans worked
• Maintain an average of 95% or higher of accuracy of claims processed, tracked as a quality score

Requirements

• Experience with overseeing processes and workflow of medical claims analysis
• Knowledge of the TPA and health benefits industry
• Strong attention to detail and ability to build out operational processes
• Superb communication, organizational, and leadership skills
• Knowledge of medical terminology and anatomy
• PC proficiency to include Microsoft Word and Excel
• Ability to multi-task and prioritize
• Strong analytical skills and knowledge of computer systems
• A natural demonstration of integrity, ethical conduct, and trustworthiness
• Ability to communicate ideas effectively and work with a wide range of internal stakeholders, including senior leaders
• Respectful to coworkers and conducts himself/herself in work-settings in a manner that is consistent with Detego Health’s core values

Preferred Skills:

• Bachelor’s degree in business administration or related field
• 5 years industry experience working with national and regional healthcare brands
• 5 years data entry experience working in a high-volume production setting

This role is foundational for those seeking to advance in the healthcare and insurance industries, offering valuable experience in claims management and processing.

Pay: From $24.00 per hour

Expected hours: No less than 40.0 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $24