Claims Processor- Junior

Specific Duties: Research and resolve UM inventory accordingly to meet productivity and quality standards to include: a. Claims reports with reconciliation needs b. Information received through Right Fax c. Information received through email d. Or any other methods of receipt (phone calls, etc.) Coordinates initial screening for UM claim reviews through claim queue Prepares administrative files for Medical Directors, UM Nurses and Case Managers Contacts provider offices to obtain clinical information for medical review by a clinician to meet Center for Medicare and Medicaid Services (CMS), state and health plan guidelines/regulations. Documents and follows up on all assigned inventory, utilizing online systems and procedures, according to established guidelines Maintains knowledge of various health plan partner benefits, networks, CMS regulations and health plan partner policies Utilize experience and judgment to plan, accomplish goals and effectively resolve each assigned task Receives and responds to telephone calls through the UM Phone Queue, as needed Performs all other related duties as assigned Must have qualifications/experience: High School Diploma or GED equivalent Two or more years managed care experience in Prior Authorization or Claim Review Medical Terminology, ICD9/ICD10 and CPT knowledge Proficient with Medicare processing guidelines, working knowledge of medical contracts Exceptional ability to organize, prioritize and communicate effectively. Shift Start/End Time: Monday Friday between the hours of 7:30 am to 6:00 pm Dress Code: Business Casual Work 

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Reference number US_EN_1_115854_11996192