Processor IV

$44,706 - $53,316/Yr

1199seiu - New York, NY

posted 4 months ago

Full-time
New York, NY

About the position

The Processor IV position within the Medical Claims department is a critical role that involves the review and processing of medical claims to ensure accuracy and compliance with established policies and procedures. This position is based in New York, NY, and operates in a hybrid work environment, allowing for a combination of in-office and remote work. The Processor IV will be responsible for handling various aspects of medical claims processing, including reviewing suspense reasons, verifying information in the medical claims system, and applying contractual benefits and medical policies to finalize claims. In this role, the Processor IV will access medical claim images and reference materials to assist in the claims review process. They will also handle adjustments and reversals of previously paid claims, ensuring that all actions taken are in accordance with operational procedures. The position requires the ability to manage call tracking tickets, research eligibility issues, and complete necessary forms for refunds and inquiries. Additionally, the Processor IV will be tasked with handling complex edits and manual pricing, as well as performing any additional duties or projects assigned by management. The ideal candidate for this position will have a strong background in medical claims processing, with a thorough understanding of various medical services and procedures. They will need to demonstrate excellent communication skills, both oral and written, and possess strong organizational abilities to manage multiple tasks effectively. The role demands a high level of accuracy in data entry and the ability to meet performance standards, including attendance and punctuality. Overall, the Processor IV plays a vital role in ensuring the efficient processing of medical claims, contributing to the overall success of the department and the organization.

Responsibilities

  • Review suspense reason of medical claims and determine actions to be taken to handle edit
  • Verify information entered in Medical claims system (QNXT) is correct, including patient's name, provider tax identification number and suffix, diagnosis and procedure codes
  • Access medical claim image and other reference materials as appropriate
  • Apply contractual benefits, medical policy, and operational procedures to finalize claim
  • Handle adjustments and reversals of previously paid medical claims as necessary
  • Review and handle call tracking tickets as assigned
  • Research eligibility issues in Vitech (V3)
  • Review and handle EOBs as assigned
  • Research and complete request refund form
  • Complete medical inquiry form for Medical Consultant
  • Handle complex edits and manual pricing
  • Perform additional duties and projects as assigned by management

Requirements

  • High School Diploma or GED required, some college or degree preferred
  • Minimum of two (2) years' experience examining and resolving medical claims in a health insurance or benefits environment required
  • Thorough knowledge of medical claims processing including major medical, office visits, surgery, anesthesia, lab and x-rays required
  • Knowledge of eligibility systems including Coordination of Benefits (COB) and Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits required
  • Excellent oral and written communication skills
  • Demonstrated organizational skills with ability to multi-task and follow up
  • Good problem-solving skills with ability to work independently and as a team player
  • Excellent data entry skills with a minimum 6,000 KPH and 6% or less error rate required
  • Must meet performance standards including attendance and punctuality
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