The Claims Review Representative 3 makes appropriate claim decision based on strong knowledge of claims procedures, contract provisions, and state and federal legislation. The Claims Review Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
Responsibilities
The Claims Review Representative 3 partners with professional staff on pre-screening review by applying guidance, and making an appropriate decision which may include interpretation of provider information or data. Decisions are typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
Work-At-Home Requirements
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Required Qualifications
1 - 3 years of technical experience
3 years of strong and proven experience with processing and adjudicating medical claims
Proficiency in Microsoft Office applications including Word, Excel and Outlook
Working knowledge of computers or a demonstrated technical aptitude
Experience in working under processes that require production and metrics
Ability to quickly learn new systems
Ability to manage and prioritize tasks based on business need
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
Associate's or Bachelor's Degree
Knowledge with CPT, ICD9, and ICD10 terminology/codes
CAS and/or CCP experience
CIS/ CIS Pro experience
Finance knowledge
Additional Information
* Schedule: Monday to Friday with Availability between 6am to 5:30pm
* Associates earn vacation on a biweekly basis (18 days per calendar year). Vacation time can be taken after six months of employment. NO Exceptions.
Employer job 
90 Day Old Job 
