50 applicants

Company

TriWest Healthcare Alliance · 15 hours ago

Senior Claims Reviewer Provider & Beneficiary Correspondence

Phoenix, AZ

Full-time

Remote

Mid, Senior Level

$59K/yr - $62K/yr

3+ years exp

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Responsibilities

Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. CCI Fine-a-Code, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations.

Validates medical determinations through research of resources including regulatory manuals, computer files and documentation.

Prepares cases program payment or medical director review as indicated.

Validates all appropriate data is supplied with program invoice.

Reviews claim data for process improvements related to all aspects of claims payment.

Ensures contract compliance for timelines regarding resolution of medical claims.

Communicates effectively with management and peers.

Consistently meets medical claims processing quotas.

Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity as needed.

Performs invoice review and resolution.

Works with VA on Invoice Reconciliation.

Acts as a subject matter expert and assists supervisor and manager with questions from claims reviewer.

Provides telephone customer assistance to government employees, Veterans, providers and regional managers.

Provides support regarding clinical and coding questions.

Performs other duties as assigned.

Regular and reliable attendance is required.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Claims review experienceMedical claims reviewClaim coding experienceGovernment health care claimsClinical knowledgeCoding knowledgeSupercoderClinical Decision Support ToolCurrent Procedural TerminologyHCFA Common Procedure Coding SystemAmerican Dental codingBehavioral health claimsComputer literacy

Required

3+ years of claims review experience

If supporting TRICARE contract, must be a U.S. Citizen

If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

Knowledge of all types of Medical claims review