Credentialing Representative Consulting

Credentialing Representative Consulting

Claims Examiner Level 3

Visa US Citizen or Green Card
Hybrid Role Doral FL
Consulting Opportunity
# of seats: 2
Hybrid Schedule: In office when needed



General Purpose
Processes and Adjudicates Facility UB04 and Professional CMS 1500 claims in accordance with all claims policies contracts keeping in compliance with industry regulations and guidelines.


Duties and Responsibilities
1) Meets or exceeds claims standard of 95% or greater in the accuracy of claims processing along with meeting or exceeding overpayment and underpayment standard of 98% or greater.
2) Meet or exceed the department standard of the production quota set by type of claim.
3) Apply all claims policies contracts practices and keep in compliance with industry regulations and guidelines.
4) Must be able to work and make claims resolution with limited supervision.
5) Confirm eligibility for claim billed and date of service.
6) Match and link authorization for required claims.
7) Comply with claims timeliness guidelines: Medicare noncontracted claims 30 calendar days; Medicare contracted claims 60 calendar days.
8) Proficient in and performs the application of Coordination of Benefits.
9) Proficient in and knows how to use and apply Health Plan Benefit Matrices and Division of Financial Responsibility.
10) Complies with all Company and Department Policies and Procedures.
11) Proficient with Federal and State requirements in claims processing.
12) Proficient understanding the appeals and dispute process of Medicare claims.
13) Processes (PDR) Provider dispute resolution claims (CMS 1500 & UB 04)
14) Proficient in rate application for outpatient PPS & inpatient DRG facility ASC and APC payment methods to Medicare line of business.
15) Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid error.
16) Process and adjudicate claims in date received order. (First in first out)
17) Resolve any grievances and complaints received through Claims Customer Service Call Center.
18) Prompt and accurate response to claims related questions from Supervisors and Management.
19) Identify claims that are a potential Stop Loss case.
20) Identify any overpayments or underpayments in a review and or history search. Follow department protocol for reporting and followup.
21) When needed assist in claims audit activities.
22) Must be able to sit for lengthy periods of time up to (3) hours at a time.
23) Must be able to lift a maximum of 10 pounds.
24) Perform as required any task or assignment by the Claims Supervisory Team and Upper Management.

Qualifications:
1. Handson experience with HMO claims functions regulations and guidelines.
2. High school diploma or equivalent.
3. Proficient in medical terminology CPT ICD9 Revenue codes HCPCS codes.
4. Excellent verbal and written communication skills.
5. Excellent organizational skills and interpersonal skills.
6. Experience with EZCAP system for claims processing.
7. Personal Qualities
Arrives daily to work on time.
Reports to work daily.
Ability to function and perform effectively under time constraints.
Ability to follow directions and multitask.
Have a genuine willingness to accept responsibility and desire to learn new things.

Preferred Skills:
Previous experience processing Medicare claims