Job Summary: Reviews claims and makes payment and benefit determination. Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required. Essential Responsibilities: Reviews claims and makes payment determination with authorization limit to $9,999 per claim. Conducts research regarding medical appropriateness, coordination of benefits issues, fraud and abuse, and third party liability. Checks with Lead and Supervisor for any claim exceeding $9,999. Provides input to Supervisor regarding trends related to training, education to enhance department production and processes. Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA. Proactively works to ensure claims are review & processed timely. Basic Qualifications: Experience Three (3) to five (5) years Medical claims processing experience in a HMO/Indemnity environment including technical research and analysis experience. Claims System OCPS; Windows NT; Word, Excel, Lotus Notes. Excellent skills in communication Medical Claims Processing. CPT, ICD-9, Medical Terminology, COB/TPL/WC Demonstrate ability to utilize Medical Terminology and International Classification Diagnosis (ICD-9), HCPCS&CPT coding at a level appropriate to the job. Education High School Diploma/GED License, Certification, Registration N/A Additional Requirements: Preferred Qualifications: + + Medical Terminology Certificate Preferred Notes: Candidate must reside in Southern California. No exceptions
Trach/Gtube 8-12hr/d x 5-7d/wk As a Home Health Nurse (RN/LPN) you will be called to care when youre needed most. As part of Interim Healthcare Home Health, youll support a full range of patient services to bring comfort and dignity to our clients. What we offer...
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Engineer (I, II, SR) Salt Lake City, UT or Portland, OR #112234 Date: Nov 28, 2024 Location: SALT LAKE CITY, UT, US, 84116 Company: PacifiCorp JOIN OUR TEAM Seeking ENTRY LEVEL , CAREER LEVEL , and SENIOR Civil Engineers: If you ever...