Medicare Claims Processor

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

📋 Description

• Review and supervise the adjudication of Medicare insurance claims, ranging from straightforward data entry to intricate specialty claim investigations.

• Analyze and process insurance claims, ensuring their validity in line with all CMS guidelines.

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

• Guarantee the accuracy of entered data and maintain comprehensive records.

• Analyze claims to ascertain the extent of liability from insurance carriers.

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

• Assess payment levels and arrive at conclusive payment determinations.

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

• Achieve production and quality standards while managing work queues per departmental expectations.

• Communicate effectively with both internal and external colleagues.

• Elevate issues to the next level of supervision when appropriate.

• Participate in required training sessions and demonstrate proficiency and willingness to learn.

• Read and interpret explanations of benefits (EOBs).

• Provide mentorship to less experienced staff as assigned by leadership.

• Uphold patient/member confidentiality in accordance with PHI and HIPAA regulations.

⛳️ 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.

• One (1) year of experience with CMS/professional and UB/institutional claims.

• One (1) year of customer service experience.

• Ability to determine whether to return, deny, or approve claims while adhering to organizational policies and procedures.

• Proficient understanding of administrative and clerical procedures and systems, including word processing and file management.

• Capacity to follow directions and navigate multiple systems concurrently.

• Exceptional written and verbal communication skills, along with strong customer service and interpersonal abilities.

• Ability to resolve issues using predefined methods and guidelines.

• Proficiency in applying mathematics to adjudicate claims.

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

• Familiarity with Medicare medical insurance terminology, procedure and diagnosis codes, and HIPAA requirements.

• Ability to sit for prolonged periods.

• Comfortable working at times with minimal social interaction.

• 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 preferred.

• Familiarity with navigating EPIC software programs preferred.

🏝️ Benefits

• Full-time schedule: 40 scheduled hours per week.

• Non-exempt employment status.