Claims reviewer

Position Title: 60804V Claims Reviewer

Location: Remote

Duration: 6 Months

Schedule: Ability to cover any work shift

Pay Rate: XX29.00/Hour.

Job Summary:

• Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services as it relates to claims inquiry resolution audit and related functions.
• Applies clinical coding and processing knowledge to conduct review of claims. Validates and compiles information necessary to prepare cases for program payment.
• Ensures adherence to Government contract requirements.
• Provides clinical and codingrelated information to medical director providers peer reviewers Claims Administration Program Integrity Quality Management and/or the Claims Subcontractor as needed. Advises clinical and nonclinical staff on claims and coding questions.

Education & Experience:

Required

• High School Diploma or GED
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 2 years of claims review experience
• Knowledgeable in medical institutional and behavioral health claims processes
• Demonstrated ability to communicate effectively both verbally and in writing
• Experience using MS Word Excel and Office

Preferred

• Government claims experience
• Claims coding certification or equivalent experience
• Intermediate proficiency with MS Office suite

Key Responsibilities:

• Validates claim outcomes for accuracy and routes for adjustment as necessary.
• Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.
• Validates claims submission details against systems data.
• Adheres to all desktop procedures for assigned function.
• Identifies and appropriately communicates processing discrepancies or trends.
• Reviews claim data for process improvements.
• Communicates effectively and professionally with internal and external partners.
• Consistently meets or exceeds individual performance expectations.
• Identifies and reports potential quality or fraud issues to per established procedures.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

1. Technical Skills

Thorough knowledge of policies and procedures Managed Care concepts and medical terminology. Proficient with claim and coding tools and resources Clinical Decision Support Tool Current Procedural Terminology Health Care Financing Administration Common Procedure Coding System and American Dental coding. Ability to meet or exceed production standards in compliance with contract.

1. Team building / Team Player

Influence the actions and opinions of others in a positive direction and build group commitment.

1. Organizational Skills

Ability to organize people or tasks adjust to priorities learn systems within time constraints and with available resources detail oriented.

1. High Intensity Environment

Ability to function in a fastpaced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

1. Coping / Flexibility

Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problemsolving approach is required.

1. Computer Literacy

Ability to function in a multisystem Microsoft environment using Word Outlook TriWest Intranet the Internet and department software applications.

1. Communication / People Skills

Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

1. Commitment to Task

Ability to conform to established policies and procedures; exhibit high motivation.

1. Coaching / Training / Mentoring

Actively foster actions required for desired business outcomes through ongoing constructive feedback.

Working Conditions

• Ability to cover any work shift
• Ability to work overtime if needed
• Onsite: works within a standard office environment
• Remote: private and secure workspace and workstation with highspeed internet is required
• Extensive computers work with prolonged sitting wearing of headset typing speaking on a phone