Claims Processor III / Job Req 788850824

PRINCIPAL RESPONSIBILITIES:

Under general direction of the Manager, Claims Production and Claims Processing Supervisor, this position is responsible for the accurate review, entry and processing of all claims received for payment by AAH.

Principal responsibilities include:

• Research claims for completion and appropriateness.
• Review and handle rejected claims as necessary.
• Evaluate HealthSuite error screen and base payment determination using AAH claims processing guidelines.
• Utilize Claims Department policies & procedures, workflows and manuals to meet Departmental production and quality metrics.
• Routinely exceed established Departmental individual production standards and collaborate with other Claims staff to ensure departmental compliance targets are met. The current production standard for this position is a minimum average of 13 claims per hour.
• Meet or exceed a financial and procedural accuracy standard of 97%.
• Review highly complex claims and edits to determine the appropriate handling for each including paying, denying or suspending for Claims Processing Supervisor review.
• Perform complex adjustments and manually price claims as needed.
• Review high dollar pricing and assist with adjustment projects on an ad-hoc basis.
• Review and resolve Service Requests, as required, within established timeframes.
• Communicate identified issues with claims and claims processes to Supervisor or Manager and propose resolutions.
• Actively participate and collaborate with entire department to continuously improve workflows and performance.
• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Process or adjust claims of a more complex type using the claims processing system.
• Review and analyze claims for routing to appropriate queues for resolution.
• Routinely exceed Departmental performance and quality metrics.
• Review and resolve Service Requests.
• Comply with AAH's Code of Conduct, and all regulatory requirements.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and other objects weighing between 0 and 20 lbs.

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• High School Diploma or equivalent is required.
• 3-5 years as a medical claims processor, meeting or exceeding production and quality standards.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Must have detailed knowledge of CPT, HCPCS, ICD-10 and revenue codes.
• Must have detailed knowledge of CMS1500 and UB04 forms and fields.
• Experience with processing Medi-Cal or Medicaid program claims required.
• Experience in RAM HealthSuite preferred.
• Ability to work in cooperation with others.
• Ability to communicate effectively, both verbally and in writing.
• Ability to handle multiple projects simultaneously and balance priorities.
• Experience in the use of Microsoft Office software (Outlook, Word, Excel).

SALARY RANGE: $34.80 - $52.21 HOURLY

The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.