Medicare Claims Processor

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

👻 Ghost score 10%

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Analyze and process Medicare insurance claims in accordance with CMS guidelines • Determine whether to return, deny, or pay claims according to organizational policies and procedures • Screen, review, evaluate online entry, correct errors, and perform quality control for final adjudication of paper/electronic claims • Ensure accuracy of data entered and maintain records • Analyze claims to determine insurance carrier liability • Resolve claim edits, review history records, and determine benefit eligibility for services • Review payment levels and arrive at final payment determinations • Interpret contract benefits and adjudicate claims according to Medicare claims processing guidelines • Meet production and quality standards and maintain work queues • Communicate effectively with internal and external colleagues • Escalate issues to the next level of supervision as appropriate • Attend required training and demonstrate proficiency • Read and interpret explanations of benefits (EOBs) • Mentor less experienced staff as assigned • Maintain patient/member confidentiality under PHI and HIPAA guidelines • Report to the Medicare Claims Supervisor

🎯 Requirements

• Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience • One (1) year of Medicare claims processing experience • One (1) year of experience working with CMS/professional and UB/institutional claims • One (1) year of customer service experience • Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience (preferred) • Three (3) years of Medicare claims processing experience (preferred) • Three (3) plus years of medical or institutional claims processing and customer service experience (preferred) • Experience in Medicare medical insurance and Medicare supplement preferred • Familiarity navigating the EPIC software programs preferred • Ability to sit for extended periods of time • Comfortable working at times with limited social interaction • Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records • Ability to take direction and navigate through multiple systems simultaneously • Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette • Ability to solve problems with predefined methods and guidelines • Ability to use mathematics to adjudicate claims • Ability to understand medical insurance requirements for payment and basic knowledge of covered services • Knowledge and understanding of medical terminology, third party payors and insurance preferred • Attention to detail, organization, independent work, critical thinking, time management, and ability to perform multiple tasks simultaneously • Working knowledge of Medicare medical insurance terminology, procedure and diagnosis codes, and HIPPA requirements

🏖️ Benefits

• Full-time position • 40 scheduled hours per week