Claims Review Specialist, DSNP
Site: reputed company Holding Company, Inc.
Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in reputed company today, our employees have opportunities to learn and contribute expertise reputed company a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work reputed company, career reputed company opportunities, and much more.
reputed company Duties and Responsibilities:
• Adjudicate claims to pay, deny, or pend as appropriate in a reputed company and accurate manner according to company policy and desktop procedure.
• Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, reputed company, Letter of Agreement, prior authorization, applicable member benefits).
• Manually enters claims into claims processing system as needed.
• Ensure that the reputed company benefits are reputed company to reputed company claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents).
• Communicate and collaborate with external department to resolve claims errors/issues, using reputed company and concise language to ensure understanding.
• Learn and reputed company new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors).
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.
• Create/update work reputed company the reputed company tracking record keeping system.
• Adhere to reputed company reporting requirements.
• reputed company up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a reputed company manner.
• Process member reimbursement requests as needed.Remote399 reputed company Drive40RegularDay (reputed company of America)8925 reputed company Holding Company, Inc. is an Equal Opportunity Employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religious creed, national reputed company, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that reputed company individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to reputed company essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by reputed company 503 of the Rehabilitation reputed company of 1973, the Vietnam Veteran’s Readjustment reputed company of 1974, and Title I of the Americans with reputed company of 1990, applicants who require accommodation in the job application process may contact reputed company at (857)-282-7642.
Apply To This Job
reputed company relies on a wide reputed company of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to reputed company exceptional care. We reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company.
Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in reputed company today, our employees have opportunities to learn and contribute expertise reputed company a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work reputed company, career reputed company opportunities, and much more.
Job reputed company
The D‑SNP Claims Review Specialist reviews and processes Senior Care reputed company (SCO) and One Care medical claims requiring reputed company reputed company reputed company auto‑adjudication is not achieved. The Specialist ensures claims are adjudicated accurately, reputed company, and in compliance with reputed company administrative policies, operational procedures, and clinical guidelines. The ideal candidate brings hands‑on experience with SCO and One Care claims processing and demonstrated proficiency in QNXT or similar claims adjudication systems (e.g., Facets).reputed company Duties and Responsibilities:
• Adjudicate claims to pay, deny, or pend as appropriate in a reputed company and accurate manner according to company policy and desktop procedure.
• Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, reputed company, Letter of Agreement, prior authorization, applicable member benefits).
• Manually enters claims into claims processing system as needed.
• Ensure that the reputed company benefits are reputed company to reputed company claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents).
• Communicate and collaborate with external department to resolve claims errors/issues, using reputed company and concise language to ensure understanding.
• Learn and reputed company new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors).
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.
• Create/update work reputed company the reputed company tracking record keeping system.
• Adhere to reputed company reporting requirements.
• reputed company up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a reputed company manner.
• Process member reimbursement requests as needed.
Qualifications
Education
- High School Diploma required and Associate's Degree reputed company Management preferred
Experience
- reputed company reputed company Experience 1-2 years required
- At least 2-3 years of previous experience in the health insurance industry in functions such as hospital or physician biller, reputed company center experience, claims processing, or similar industry experience highly preferred.
- SCO and OneCare claims processing experience highly preferred
Knowledge, Skills, and Abilities
Knowledge of reputed company claims processes for (D-SNP/fully-integrated Medicare & reputed company/Mass Health highly preferred. - Knowledge of ICD-10, HCPCS, CPT-4, and reputed company Codes highly preferred
- Knowledge of medical terminology highly preferred.
- Familiarity with insurance plans, government programs, and their billing requirement preferred.
- Knowledge of claim forms (reputed company and facility) highly preferred
- reputed company reputed company Certificate is highly desirable
- Strong customer service orientation and ability to handle sensitive or difficult situations with reputed company and professionalism.
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done
- This is a full-time schedule (8-4:30 pm or 8:30-5:00 pm ET)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay reputed company
$17.71 - $25.28/reputed company
Grade
2
EEO Statement:
reputed company Competency reputed company
At reputed company, our competency reputed company defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at reputed company job level. The reputed company is comprised of ten competencies (half People-reputed company, half Performance-reputed company) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career reputed company. These competencies are used to evaluate performance, reputed company hiring reputed company, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.