Medicare Claims Processor

This is a fully remote position, open to applicants in United States.

📋 Description

• Analyze and process Medicare insurance claims in accordance with CMS guidelines.

• Assess whether to return, deny, or approve claims based on organizational policies and procedures.

• Screen, review, and evaluate online submissions, rectify errors, and conduct quality control for the final adjudication of both paper and electronic claims.

• Ensure the accuracy of data entry and maintain comprehensive records.

• Analyze claims to ascertain insurance carrier liability.

• Resolve claim edits, review historical records, and establish benefit eligibility for services rendered.

• Review payment levels and make final payment determinations.

• Interpret contract benefits and adjudicate claims in accordance with Medicare claims processing guidelines.

• Meet production and quality standards while managing work queues effectively.

• Communicate proficiently with both internal and external colleagues.

• Escalate issues to the appropriate supervisory level as necessary.

• Participate in required training and demonstrate proficiency.

• Read and interpret explanations of benefits (EOBs).

• Mentor less experienced staff as assigned.

• Uphold patient/member confidentiality in compliance with PHI and HIPAA guidelines.

• Report directly to the Medicare Claims Supervisor.

⛳️ Requirements

• Associate Degree in a related healthcare field OR a high school diploma or equivalent AND three (3) years of experience in healthcare claims billing and processing.

• At least one (1) year of Medicare claims processing experience.

• Minimum of 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 a related healthcare field, OR four (4) years of equivalent industry experience (preferred).

• Three (3) years of Medicare claims processing experience (preferred).

• More than three (3) years of experience in medical or institutional claims processing and customer service (preferred).

• Experience in Medicare medical insurance and Medicare supplement is preferred.

• Familiarity with navigating the EPIC software programs is preferred.

• Ability to sit for extended periods of time.

• Comfortable working with limited social interaction at times.

• Working knowledge of administrative and clerical procedures and systems, including word processing and file management.

• Ability to follow directions and navigate through multiple systems simultaneously.

• Excellent written and oral communication skills, customer service capabilities, interpersonal skills, and telephone etiquette.

• Ability to solve problems using predefined methods and guidelines.

• Proficiency in mathematics for claims adjudication.

• Understanding of medical insurance requirements for payment and basic knowledge of covered services.

• Knowledge of medical terminology, third-party payors, and insurance is preferred.

• Strong attention to detail, organizational skills, independent work ethic, critical thinking, and time management abilities, with the capacity to perform multiple tasks concurrently.

• Working knowledge of Medicare medical insurance terminology, procedure and diagnosis codes, and HIPAA requirements.

🏝️ Benefits

• Full-time position.

• 40 scheduled hours per week.