Claims Reviewer- VA & TW Internal Claims Queries

October 9, 2024

Company: Vail

Industry: Private

Employment Type:- Full Time

Work Hours:- 8 Hours

Locations:- USA

Full Job Description:-

Job Summary

Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services, as it relates to claims inquiry, resolution, audit, and related functions. Applies clinical, coding, and processing knowledge to conduct review of claims. Validates and compiles information necessary to prepare cases for program payment. Ensures adherence to Government contract requirements. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed. Advises clinical and non-clinical staff on claims and coding questions.

Education & Experience

Required:

High School Diploma or GED
2 years of claims review experience
Knowledgeable in medical, institutional, and behavioral health claims processes
Demonstrated ability to communicate effectively, both verbally and in writing
Experience using MS Word, Excel, and Office

Preferred

Government claims experience
Claims coding certification or equivalent experience
Intermediate proficiency with MS Office suite

Key Responsibilities

Validates claim outcomes for accuracy and routes for adjustment, as necessary.
Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.
Validates claims submission details against systems data.
Adheres to all desktop procedures for assigned function.
Identifies and appropriately communicates processing discrepancies or trends.
Reviews claim data for process improvements.
Communicates effectively and professionally with internal and external partners.
Consistently meets or exceeds individual performance expectations.
Identifies and reports potential quality or fraud issues to per established procedures.
Performs other duties as assigned.
Regular and reliable attendance is required.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.
Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

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Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract.

Working Conditions

Ability to cover any work shift
Ability to work overtime, if needed
Onsite: works within a standard office environment
Remote: private and secure workspace and workstation with high-speed internet is required
Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone