What are the responsibilities and job description for the Claims Reviewer- TW Internal Claims Inquiries position at TriWest Healthcare Alliance?
Profile
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:
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.
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
Working Conditions
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
- U.S. Citizenship
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 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
- Government claims experience
- Claims coding certification or equivalent experience
- Intermediate proficiency with MS Office suite
- 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.
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.
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
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
