Priority Claims Specialist III
Hanger, Inc.
Claims Specialist
Point32Health
full-time
Posted on:
Location: Massachusetts • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- Process complex claims: fully research and resolve complex issues and problem codes for proper adjudication
- Manually apply specific product or benefit rules to claims and manually calculate/apply pricing when necessary
- Ensure claim payment correctly reflects Point32Health’s status as primary or secondary payer through coordination of benefits
- Determine member eligibility and verify services are allowable under member benefit plan and required authorizations/referrals/pre-registrations
- Process complex claim adjustments: review requests, determine need for re-adjudication, research provider payment inquiries
- Examine and correct/update claim data; prepare and enter adjustments with appropriate back out and adjustment reason codes
- Assist partner departments and promptly research and resolve escalated issues from other departments and management
- Monitor pending claims and adjustments daily to ensure timely release for adjudication and meet quality/production standards
- Participate in identifying opportunities for process improvements and serve as SME for documentation, projects, and testing
- Act as role model and mentor to core claims processors and provide back up support to other department areas
- Responsible for timely and accurate processing of Member Reimbursements and comply with department/company guidelines and policies
Requirements
- High school diploma or equivalent (required)
- Associate’s degree or equivalent business experience in claims/customer service environment (preferred)
- 2-4 years experience as a Point32Health Core Claims Processor or similar claims processing/customer service experience (required)
- Working knowledge of Microsoft Office applications and internet navigation (preferred)
- Experience with Point32Health internal applications (Diamond, Macess, Webchannels) (preferred)
- Understanding of managed care concepts
- Strong understanding of CPT, ICD-9/ICD-10, HCPCS coding guidelines and CMS1500 & UB04 billing forms (preferred)
- Knowledge of Coordination of Benefits (COB) and Third-Party Liability (TPL) rules and NAIC COB guidelines
- Knowledge of healthcare compliance and regulations including HIPAA, Medicare, Medicaid in COB and TPL processes
- Proficiency identifying errors, overpayments, underpayments and taking corrective actions
- Strong problem solving and analytical skills; ability to multi-task
- Advanced verbal and written communication skills
- Ability to work independently and as part of a team
- Ability to sit for extended durations and use telephone/headset and PC/keyboard; may be required to work additional hours
