On-site Medical Claims Examiner

AliviMiami, Florida

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Overview

Schedule

Full-time

Career level

Senior-level

Remote

On-site

Benefits

Health Insurance

Job Description

SUMMARY

This position is intended to provide billing and claims management support to Alivi Specialty Networks and Business Process Outsourcing (BPO) Services. The Medical Claims Examiner will ensure all claims received comply with all health plan, regulatory, contractual, compliance, and Alivi billing guidelines and processes.

DUTIES & RESPONSIBILITIES

Responsible for accurate and timely adjudication of professional and institutional claims according to state and federal regulations.
Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately.
Demonstrate skills in problem solving, benefit plan, and provider contract Interpretation.
Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-10 Codes, under the correct provider contract and member benefits.
Responds to provider disputes in a timely and accurate manner.
Research provider disputes to ensure appropriate claims dispute resolutions.
Works Directly with Clinical Review Board and Network Operations Team to resolve complex issues or disputes.
Adjudicates claims that have been overturned by the Clinical Review Board or Network Operations Team.
Generates written correspondence to members, providers, and regulatory agencies.
Responds and assists other departments with complex issues for resolution or affirmation of previously processed claims and existing guidelines.
Determines and processes overpayments (provider refunds) and reimbursement requests according to specific state and/or federal guidelines or as agreed to in provider contract.
Determines and processes underpayments (internal errors) and provider reimbursement requests, which may involve the use of spreadsheet research and correspondence.
Maintains the department’s claim edit rules and processing claims according to client specific verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing.
Identifies trends in claims flows and suggests process improvements.
Assist in preparation with Claims Audits.
This position description identifies the responsibilities and tasks typically associated with the performance of the position.

REQUIREMENTS

High School diploma or equivalent.
3 years’ work experience in claims operations environment in the healthcare insurance processing Medicare.
Hands-on working experience processing medical claims in insurance industry.
Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees).
Self-starter, ability to work independently and in a team environment.
Strategic, analytical, process oriented and must have critical thinking skills.
Excellent written and verbal communication skills.
Ability to manage multiple priorities.
Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities.
Works well under pressure.
Proficient with Excel, PowerPoint, Word & Outlook.
Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes and Revenue Codes.
Knowledge of Correct Coding (CCI) Edits.
Experience in gathering all necessary documentation in preparation of Delegation Audits.
Detailed knowledge of electronic billing processes universal billing forms.
Knowledge of CMS/ACHA Regulations is desirable.
Previous Experience using Health Suite is desirable.Certified Professional Coder (CPC) is desirable.

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FAQs About On-site Medical Claims Examiner Jobs at Alivi

What is the work location for this position at Alivi?

This job at Alivi is located in Miami, Florida, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.

What pay range can candidates expect for this role at Alivi?

Employer has not shared pay details for this role.

What employment applies to this position at Alivi?

Alivi lists this role as a Full-time position.

What experience level is required for this role at Alivi?

Alivi is looking for a candidate with "Senior-level" experience level.

What benefits are offered by Alivi for this role?

Alivi offers Health Insurance for this position. Actual benefits may vary depending on the employer's policies and employment terms.

What is the process to apply for this position at Alivi?

You can apply for this role at Alivi either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.