PARTICIPANT CLAIMS LIAISON

Exposure Category II

Basic Purpose and Scope

Under assigned supervision by the Associate Program Director/Center Manager, is responsible for, but not limited to processing medical claims and interacting with providers on a routine basis.

Responsibilities

• Processes medical claims received from Providers for payment.
• Reviews and verifies medical records both electronic and hard copy ensuring accuracy and completeness.
• Evaluates system coding to validate pricing and claims payments to ensure claims are processed in accordance with provider contracts, participant benefits, and authorization requirements.
• Manages claims inquiries and individual Provider requests.
• Requests participant information/reports from specialist, health care facilities and other providers.
• Analyze claims and data to improve operational efficiency, productivity, and accuracy.
• Act as a subject matter expert for claims system functionality and capabilities.
• Manage underpayment/overpayment recovery processes to ensure claims are reprocessed in a timely manner.
• Monitor mis-paid claims, develop, and implement ongoing tracking mechanisms and recommend activities to reduce/avoid mis-paid claims from re-occurring.
• Maintains confidentiality.
• Adheres to and reflects organizational values in daily work.
• Serves on agency committees as may be assigned.
• Maintains an obligation to report wrongdoing/violation of agency policies, applicable federal, state and local laws, and rules and regulations, pertaining to agency operations, to immediate supervisor or identified compliance officer.
• Completes all mandatory in-service education programs and completes any other additional in-service hours that are minimally required for the position.

The above examples of work may not be a complete statement of all assignments that may be inherent to the position. Other duties may be assigned as deemed necessary and appropriate by the Executive Program Officer, Associate Program Director, and/or Accounting Manager.

Total Senior Care, Inc. reserves the right to add, delete or otherwise alter assigned duties at any time. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The minimum qualifications listed are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum Requirements

• Required Education: Training and knowledge of medical records technology, claims processing, or equivalent program or high school diploma and four years of related experience in a medical records and/or medical claims processing environment, or equivalent combination of experience and education.

• Required Experience: 2 years (or minimum of related experience above) of related work experience in a healthcare environment and processing of medical claims; skilled in computer operations and use/application of Microsoft Office software; and demonstrated organizational abilities. Possesses strong/broad understanding of the claims analyst process, medical terminology, and claims processing procedures.
• Desired or Preferred Knowledge, Skills and/or Abilities: Effective verbal and written communication skills; strong attention to detail; organizational skills; customer service and telephone skills including receiving incoming calls and contacting external physician offices; familiarity and competence with standard office machines such as copier, calculator, fax machine, etc.; acceptable driver’s license and use of automobile during working hours. Healthcare experience in a managed care organization, preferred.

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Incumbent Name: ____________________________________

Incumbent Signature: _____________________________ Date: ______________