Medicare Claims Processor

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Come join our Peak Health team at WVU Medicine as a Medicare Insurance Claims Processer, contributing to the foundation for an innovative, new health plan. This position will report to the Medicare Claims Supervisor, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team reviews and oversees the adjudication of claims ranging from simple data entry to complex specialty claim research. The Medicare Claims team analyzes and processes insurance claims, checking for validity in accordance with all CMS guidelines. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluates online entry, error correction, and quality control for final adjudication of paper/electronic claims.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

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

EXPERIENCE:

1. One (1) year of Medicare claims processing experience

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

3. One (1) year of customer service experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience

EXPERIENCE:

1. Three (3) years of Medicare claims processing experience

2. Three (3) plus years of medical or institutional claims processing and customer service experience

3. Experience in Medicare medical insurance and Medicare supplement preferred

4. Familiarity navigating the EPIC software programs

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Ensure accuracy of data entered and record maintenance

2. Analyze claims to determine the extent of insurance carrier liability

3. Resolve claim edits, review history records, and determine benefit eligibility for service 

4. Review payment levels to arrive at final payment determination

5. Interpret contract benefits and adjudicate claims in accordance with the specific Medicare claims processing guidelines

6. Meet all production and quality standards, maintaining Work queues according to department standards

7. Effectively communicate with internal and external colleagues

8. Elevate issues to next level of supervision, as appropriate

9. Attend all required training classes, demonstrating proficiency and the ability to learn

10. Read and interpret explanation of benefits (EOBs)

11. Provide mentorship to less experienced staff as deemed necessary and assigned by leadership

12. Other duties as deemed appropriate by the Claims Supervisor/Manager 

13. Maintain strict confidentially of patient/member as specified under PHI and HIPAA guidelines

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit for extended periods of time

2. Comfortable working at times with limited social interaction

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard/hybrid/remote office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)

2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access, MS Teams) Internet Explorer and EPIC

SKILLS AND ABILITIES:

1. Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

2. Ability to take direction and to navigate through multiple systems simultaneously.

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

4. Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.

5. Ability to use mathematics to adjudicate claims.

6. Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services.

7. Knowledge and understanding of medical terminology, third party payors and insurance preferred.

8. Requires attention to detail, the ability to be organized, ability to work independently, ability to apply critical thinking, time management and to be able to perform multiple tasks simultaneously.

9. Maintain an open, a positive and a collaborative perspective with internal and external colleagues and leadership.

10. Working knowledge of Medicare medical insurance terminology, procedure, diagnosis codes and HIPPA requirements.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2902 PHH Claims Operations