Claim Benefit SpecialistPrimary Location: Pittsburgh, Pennsylvania
Additional Locations: PA-Pittsburgh Apply
62078Fundamental Components: Analyzes and approves routine claims that cannot be auto adjudicated. Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process. Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues. Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements. May facilitate training when considered topic subject matter expert. In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor). Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools). Background Experience:
- Experience in a production based environment with an emphasis on quality outcomes
- Medical claim processing experience is preferred
- Strong computer navigational skills, Medicare experience, medical terminology and coding certification are desirable
- High School or GED equivalent.
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