Processor IV

Responsibilities:

·        Review suspense reason of medical claims and determine actions to be taken to handle edit

·        Verify information entered in Medical claims system (QNXT) is correct, including patient’s name, provider tax identification number and suffix, diagnosis and procedure codes

·        Access medical claim image and other reference materials as appropriate

·        Apply contractual benefits, medical policy, and operational procedures to finalize claim

·        Handle adjustments and reversals of previously paid medical claims as necessary

·        Review and handle call tracking tickets as assigned

·        Research eligibility issues in Vitech (V3)

·        Review and handle EOBs as assigned

·        Research and complete request refund form

·        Complete medical inquiry form for Medical Consultant

·        Handle complex edits and manual pricing

·        Perform additional duties and projects as assigned by management

Qualifications:

·        High School Diploma or GED required, some college or degree preferred

·        Minimum of two (2) years’ experience examining and resolving medical claims in a health insurance or benefits environment required

·        Thorough knowledge of medical claims processing including major medical, office visits, surgery, anesthesia, lab and x-rays required

·        Knowledge of eligibility systems including Coordination of Benefits (COB) and Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits required

·        Excellent data entry skills rate required

·        Excellent oral and written communication skills

·        Demonstrated organizational skills with ability to multi-task and follow up

·        Good problem-solving skills with ability to work independently and as a team player

·        Ability to work independently and as a team player

·        Must meet performance standards including attendance and punctuality