Claims Processing Representative 3

Profile

Description

The Claims Processing Representative 3 reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Claims Processing Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

Responsibilities

The Claims Processing Representative 3 determines whether to return, deny, or pay Institutional claims following organizational policies and procedures. Conducts end to end claims audits to ensure claims are processed accurately according to benefits assignment, applicable contracts, pricing and configuration rules. Ensures Institutional claims also meet compliance guidelines. Performs claims testing on claims configuration and enhancements. 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.

Required Qualifications

High School Diploma or GED

Minimum 2 years of institutional (hospital) claims processing experience

Intermediate knowledge of APC, DRG pricing

Knowledge of Revenue Codes

Knowledge of Medicare Guidelines

Proficiency in Microsoft Office Programs, including Word, PowerPoint, Excel

Minimum 2 years of previous experience in a healthcare or medical environment

Commitment to preserving confidentiality

Must ensure designated work area is free from distractions during work hours and virtual meetings

Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

Medical terminology, CPT-4 and ICD-9 coding & Medicare experience

Experience in Quality Assurance

Knowledge of Medicare Claims Processing

Additional Information

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com