Long Beach, CA, USA
Summary Description Encounters data is essential for monitoring and measuring managed care quality, finance, utilization and compliancy with state and contractual requirements. It is a critical source of information for rate setting, HEDIS score and risk adjustment.
The Encounter team is responsible for receiving, capturing, validating, tracking submission, reconciling response files and error correcting rejections of encounters data rendered to members. The Claims Processor will be supporting with reviewing, logging, batching, creating and issuing Claims Acknowledgement letters and Return to Provider letters, processing of claims, along with handling providers inquiry to claims payment.
Key Tasks and Responsibilities
• Review for accuracy and completeness of inbound claims.
• Verify member eligibility.
• Validate calculation of the reimbursable amount.
• Create an Excel spreadsheet with necessary data items that serves as upload for payment from Finance.
• Update Itineris with necessary member, rates and provider data.
• Approve claims that are complete, eligible and accurate data elements.
• Reject claims that are incomplete, inconsistent data elements or duplicates.
• Print and mail Claims Acknowledgement letter to providers.
• Print and mail return letter to providers with rejection reason.
• Manage and respond to provider inquiries regarding claims status and payment by researching system for claims history.
• Identify issues, report to Director and propose solution.
Education & Training
• Required: High School Diploma or GED
• Preferred: Medical claims processing and billing
Knowledge and Experience
• Knowledge of CMS 1500 forms and fields.
• Knowledge of required transportation HCPCS codes, modifiers, provider Medicaid ID, TIN and NPI.
• Knowledge of state Medicare and Medicaid program guidelines and requirements.
• Strong understand of Itineris and Excel software.
• Strong data entry skills.
• Excellent customer Service.
• Strong organizational skills
• Ability to communicate efficiently with multiple areas of the organization
• Strong written and verbal communication skills
• Track claims, payment and rejections
• Ability to multi-task with frequent interruptions
• Exceptional attention to detail and accuracy
• identify missing or invalid claims data
• Abide to deadlines
• This is a Full time hourly position.
• Benefits after 60 days include medical, dental, vision, voluntary life and 401(k).
• No travel is required.
• This position requires working on a sitting position working on a computer and operating a keyboard and a mouse as well as other office equipment like phones and printers and filing documents.
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