Claims Specialist

New Season Maitland , FL 32751

Posted 3 months ago

Job Summary:

This position adjudicates the daily/weekly/monthly procurement of outbound claims to health plans. As part of this role, steps are taken to assure that unbilled claims are moved into a billed status and those claims are both HIPAA-compliant and accurate, fairly representing the service provided by the organization.

This role also identifies routine errors on claim forms referring same to management for action.

Essential Functions:

  • Observes and assures that claims data from the host database passes correctly to the clearinghouse system(s) for transmission of the claim to the health plan.

  • Maintains appropriate data files in the clearinghouse system(s) so that claims can be procured by the clearinghouse system(s).

  • Maintains billing episode changes and/or similar account maintenance when health plan information is added, deleted or modified.

  • Maintains billable service override changes and/or similar account maintenance when health plan information is added, deleted or modified.

  • Prepares and maintains claim data for the organization's Audit Worksheet on a week to week basis per current method(s).

  • Prepares and maintain claims output for grant funding and other contracted coverage sources where a standardized 837 claim is not used.

  • Identifies and procures returned claims from the clearinghouse system(s), commonly known as "front-end rejections", where a claim was not further adjudicated by the health plan.

  • Prepares and processes secondary claims according to current method(s).

  • Participates in weekly conference calls with various markets or groups as needed.

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Claims Specialist

New Season