Job Description
Senior Claims Examiner/Auditor
UST HealthProof is looking for Sr. Claims Examiner, reporting to the Claims Team Leader; the Examiner is responsible for the adjudication of healthcare claims utilizing group and payer-specific policies and procedures. Responsible for reviewing the data in the claims processing system and compare with corresponding UB04 or CMS1500. Responsible for reviewing claims attachments when necessary to determine if services rendered were medically appropriate and benefit coverage criteria have been met. Accountable for reviewing adjudication software system’s claim and line item edits to decide whether to pay claim/line item(s).
As a Sr. Claims Examiner at UST HealthProof, this is your opportunity to
• Be responsible for attending and completing the training scheduled by the client and employer.
• Be responsible for processing assigned claims based on client-specified guidelines or as directed by the team lead
• Be responsible for meeting complex claims productivity targets of claims per hour or day as set by the team lead
• Mentor junior members of the team, Collaborate with other team members on special projects as assigned by the team leads, including process documentation, training, quality audit, assist with surge activity for the client (s), or any other project as determined by the team lead
• Develop Knowledge of physician practice and hospital coding, billing and medical terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorization and other
terms, terminology, and concepts of healthcare
• Develop some level of communication with client Claims managers to address issues, concerns and take preventive measures to avoid service quality issues
• Be responsible for your attendance, time off and reporting shift timings, etc. with the prime objective of meeting and exceeding customer deliverables
• Participate in meetings and project activities outside of the primary location at locations determined by the UST management team and team lead
• Take on health plan administration projects assigned by the team lead from time to time – these projects may include provider data, authorization, enrolment, or other health plan.admin operations., performs production audits, SLAs audits focused audits and supports customer external audit activity.
You bring:
• High School degree required with one year of relevant professional healthcare claims operations for an insurance company or healthcare payor.
• Willingness to learn new skills and succeed in a new career
• Excellent verbal and written communication skills.
• Proficiency with MS Office applications, especially Word and Excel.
• Team collaborator
• ICD-10 coding is a plus, CPT and HCPCS coding, HIPAA is a plus
• Strong work ethic with the ability to multi-task is essential
• High proficiency in using MS Excel and MS Office Suite
• Good understanding and ability to analyse claims data and report, SLA, KPI, operations report, and present findings in a structured way.
• The ability to understand speak technology.
• Perform other duties as assigned.
For this role, we value:
• The ability to adapt quickly to a fast-paced environment, self-starter, and quick learner
• Excellent written and oral communication skills
• Team Player and ability to collaborate
Overall Experience level: 2 - 4 years claims processing experience; claims review/adjustment experience ideal
Location: This position will be based in Columbus OH, USA
UST
Columbus Ohio
United States
Customer Service / Call Center
(No Timezone Provided)
Job Description
Senior Claims Examiner/Auditor
UST HealthProof is looking for Sr. Claims Examiner, reporting to the Claims Team Leader; the Examiner is responsible for the adjudication of healthcare claims utilizing group and payer-specific policies and procedures. Responsible for reviewing the data in the claims processing system and compare with corresponding UB04 or CMS1500. Responsible for reviewing claims attachments when necessary to determine if services rendered were medically appropriate and benefit coverage criteria have been met. Accountable for reviewing adjudication software system’s claim and line item edits to decide whether to pay claim/line item(s).
As a Sr. Claims Examiner at UST HealthProof, this is your opportunity to
• Be responsible for attending and completing the training scheduled by the client and employer.
• Be responsible for processing assigned claims based on client-specified guidelines or as directed by the team lead
• Be responsible for meeting complex claims productivity targets of claims per hour or day as set by the team lead
• Mentor junior members of the team, Collaborate with other team members on special projects as assigned by the team leads, including process documentation, training, quality audit, assist with surge activity for the client (s), or any other project as determined by the team lead
• Develop Knowledge of physician practice and hospital coding, billing and medical terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorization and other
terms, terminology, and concepts of healthcare
• Develop some level of communication with client Claims managers to address issues, concerns and take preventive measures to avoid service quality issues
• Be responsible for your attendance, time off and reporting shift timings, etc. with the prime objective of meeting and exceeding customer deliverables
• Participate in meetings and project activities outside of the primary location at locations determined by the UST management team and team lead
• Take on health plan administration projects assigned by the team lead from time to time – these projects may include provider data, authorization, enrolment, or other health plan.admin operations., performs production audits, SLAs audits focused audits and supports customer external audit activity.
You bring:
• High School degree required with one year of relevant professional healthcare claims operations for an insurance company or healthcare payor.
• Willingness to learn new skills and succeed in a new career
• Excellent verbal and written communication skills.
• Proficiency with MS Office applications, especially Word and Excel.
• Team collaborator
• ICD-10 coding is a plus, CPT and HCPCS coding, HIPAA is a plus
• Strong work ethic with the ability to multi-task is essential
• High proficiency in using MS Excel and MS Office Suite
• Good understanding and ability to analyse claims data and report, SLA, KPI, operations report, and present findings in a structured way.
• The ability to understand speak technology.
• Perform other duties as assigned.
For this role, we value:
• The ability to adapt quickly to a fast-paced environment, self-starter, and quick learner
• Excellent written and oral communication skills
• Team Player and ability to collaborate
Overall Experience level: 2 - 4 years claims processing experience; claims review/adjustment experience ideal
Location: This position will be based in Columbus OH, USA