About the position
The Hospital Claims Processor V position at 1199SEIU Family of Funds is a full-time role that involves reviewing and processing hospital claims to ensure accurate and timely resolution. This position is essential in managing the claims workflow and requires a strong understanding of hospital claims, eligibility, benefits, and pre-authorization rules. The processor will work within a hybrid workplace arrangement, allowing for a combination of remote and in-office work. The role is classified as non-exempt and is part of the bargaining unit, indicating that it is subject to union agreements and protections. In this role, the processor will be responsible for reviewing hospital claims and determining the necessary actions to resolve any pended claims. This includes processing and evaluating claims either manually or through the claims workflow system. The processor will validate the information entered in the hospital claims module (QNXT) and determine the appropriate workflow needed to resolve discrepancies. Finalizing hospital claims will require applying knowledge of eligibility, benefits, pre-authorization rules, and contractual policies, as well as operational procedures. Additionally, the processor will be expected to review, finalize, and respond to call tracking tickets in a timely manner, addressing provider inquiries effectively. The role may also involve performing additional duties and special projects as assigned by management, making adaptability and a willingness to take on new challenges important traits for candidates.
Responsibilities
- Review hospital claims and determine action needed to resolve pended claims
- Process and evaluate hospital claims manually or through claims workflow
- Validate information entered in hospital claims module (QNXT) and determine the process needed to resolve discrepancies
- Finalize hospital claims by applying knowledge of eligibility, benefits, pre-authorization rules, contractual policy, and operational procedures
- Review, finalize, and respond to call tracking tickets in a timely manner to provider inquiries
- Perform additional duties and special projects as assigned by management
Requirements
- High School Diploma or GED required, some College or Degree preferred
- Minimum two (2) years experience entering and updating hospital or medical claims in a health insurance or benefits environment required
- Basic keyboarding skills required
- Strong knowledge of hospital claims, eligibility, benefits, and reauthorization rules; knowledge of health claims system (QNXT)
- Good knowledge of International Classification of Diseases (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes
- Demonstrated organizational skills and ability to perform multiple priorities and analytical skills with the ability to follow through on assignments
- Able to work well independently and in a team environment
- Ability to meet strict deadlines, work well under pressure and in a fast-paced environment
- Must meet performance standards including attendance and punctuality
