In this Role you will be Responsible for :
• Reviewing and researching insurance claims to determine possible payment accuracy.
• Validating Member, Provider and other Claims information.
• Determining accurate payment criteria for clearing pending claims based on defined Policy and Procedure.
• Coordinating Claim Benefits based on the Policy & Procedure.
• Maintaining productivity goals, quality standards and aging timeframes.
• Scrutinizing Medical Claim Documents and settlements.
Requirements for this role include :
• 2 + years of Claims Adjudication experience that required you to review claims rules and workflows.
• 2 years of prior experience with Xcelys software system
• MUST HAVE hands-on experience in Insurance medical claims adjudication including managing Data, Auth, COB and corrected holds
• Experience processing claims that required a working knowledge of HCPCS, ICD and CPT codes
• Experience that required a knowledge of healthcare insurance policy concepts including In Network, Out of Network providers, Deductible, Coinsurance, Co-pay, Out of Pocket, Maximum inside limits and Exclusions, State Variations.
• Regular working hours from 8:00 am to 5:00 pm (EST) unless an until we have exceptional approval from Management for the extension.
*This position is 100% remote*