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Assistant Claims Review Specialist
- 08-Jul-2019 (MST)
- Billings, MT, USA
- Full Time
This position compiles and maintains claims and appeal data and supports the Claims Review Team in an administrative capacity to allow expedited processing. This individual works closely with department members, providers and third-parties to proactively assist in researching concerns and resolving issues to the satisfaction of the client and in accordance with plan provisions. This position maintains a comprehensive understanding of the plan document(s) under their scope of responsibility.
Essential Duties and Responsibilities:
- Appeals Support
- Supports organizational processes that are critical to the workflow of the Claims Review Team.
- Provides administrative support to Claims Review Team.
- Contacts medical providers for information needed to complete appeals processing.
- Coordinates appeals meetings with internal EBMS team members.
- Coordinates medical peer review of appeals.
- Documents appeals in appropriate systems.
- Monitors and distributes appeals submitted through website to appropriate team members.
- Coordinates third-party appeals with vendors.
- Sorts and distributes daily workload, including appeals to be worked, email, mail and other duties.
- Enters data into pertinent computer systems.
- Compiles and distributes reports internally and externally as assigned.
- Works with leadership to maintain and update processes and procedures as necessary.
- Customer Service Internal/External
- Acts as a role model in demonstrating the core values in customer service delivery.
- Provides timely and thorough follow up with, internal and external customers.
- Sends letters to providers and members explaining a denial.
- Appropriately escalates difficult issues up the chain of command.
- Quality Assurance
- Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.
- Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.
- Performs self-quality monitoring in order to develop and execute plans to meet established goals.
- Provides ongoing feedback to help optimize quality performance.
- Collaborates with others and cross-departmentally to improve or streamline procedures.
- Develops new or improves current internal processes to improve quality.
- This job description in no way states or implies that these are the only duties to be performed by this employee. The employee will be required to follow any other instructions and to perform any other duties requested by his/her supervisor.Minimum Qualifications:
- H.S. Diploma or equivalent with minimum of two years experience in medical billing or related field
- Minimum of 1 year experience in clerical or customer service
- Working knowledge of computers and software including but not limited to Microsoft Office products
- Proficient 10-key and typing skills
- Demonstrated organizational, problem-solving, and analytical skills
- Strong written, oral and telephonic communication skills
- Demonstrated ability to work independently, be detail oriented, prioritize workloads, multi-task and manage priorities in order to meet deadlines
Physical Demands & Working Conditions:
Work is indoors in an office environment with moderate noise. Intermittent physical effort involving lifting of up to 25 pounds, walking, and stooping, kneeling, crouching, or crawling is required. A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time. Approximately 30% or less of the time is spent standing. Normal vision abilities required, including close vision and ability to adjust focus.