JOB SUMMARY
This job is a key member of the Helion Network Operations team that screens, reviews, evaluates, corrects errors, and/or reviews for quality control and provides final adjudication instruction of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Provides direction on corrective actions needed including but not limited to processed claims, using enrollment, benefit and historical claim processing information. This job will perform post-payment reviews and advise on corrective adjustments as deemed appropriate. This role will work across the matrix to partner with key functions, including Health Plan Operations (HPO), provider contracting, provider audit, and other key implementation stakeholders, and may support multiple health plan clients.
This job is a key member of the Helion Network Operations team that screens, reviews, evaluates, corrects errors, and/or reviews for quality control and provides final adjudication instruction of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Provides direction on corrective actions needed including but not limited to processed claims, using enrollment, benefit and historical claim processing information. This job will perform post-payment reviews and advise on corrective adjustments as deemed appropriate. This role will work across the matrix to partner with key functions, including Health Plan Operations (HPO), provider contracting, provider audit, and other key implementation stakeholders, and may support multiple health plan clients. .
ESSENTIAL RESPONSIBILITIES
Determine if claim information submitted is accurate and complete in line with requirements for bundled payment processing.
Provide processing instruction to claims adjudicator(s)
Provide resolution on claim rejections, review history records and determine benefit eligibility for service.
Review payment levels to arrive at final payment determination.
Work with provider network to solve claim inquiries.
Attend all required training classes.
Elevate issues to next level of supervision, as appropriate.
Maintain accurate records, including timekeeping records.
Other duties as assigned or requested.
EDUCATION
Minimum
High School Diploma/GEDPreferred
NoneEXPERIENCE
Experience in Health Care Revenue Cycle Industry (i.e. Billing, Claims, etc.) - Provider or Payor
To Include: Business Analysis
Required
5-10 years of related, progressive experiencePreferred
Typing speed of at least 60 words per minuteLICENSES OR CERTIFICATIONS
Required
Preferred
Experience in Health Care Revenue Cycle Industry (i.e. Billing, Claims, etc.) - Provider or Payor
To Include: Business Analysis
SKILLS
Provider Reimbursement
Microsoft Word, Excel
Oral & Written Communication Skills
Teamwork and Collaboration
Ability to take direction and to navigate through multiple systems simultaneously.
Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
Ability to use mathematics to adjudicate claims.
Ability to solve problems within pre-defined methods and guidelines.
Knowledge of operating systems specific to claim processing.
Language
No
Travel Requirement
Yes
Position Type
Remote
Teaches / trains others regularly
Frequently
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Ocassionally
Lifting: 25 to 50 pounds
Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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