Claims Process Coordinator - Health Alliance Plan

Education Required:

•  Associate’s degree in business, Healthcare, or related field.
• Related and relevant experience and a demonstrated ability to perform the duties of the position may be considered in lieu of academic requirements. Relevant work experience is defined as four (4) years prior experience in claims adjudication, claim inquiry resolution, and/or claim adjustment experience. 

Experience Required:

• Four (4) years of related experience with multiple claims screens with demonstrated ability to investigate and process claim inquiries.
• Two (2) years of experience processing claim adjustments.
• One (1) year experience with the Data iSight appeals and the Data iSight portal.

Preferred:

• Three (3) years of experience with HAP programs: Care Radius, Facets, Pega.
• Experience with the Data iSight portal.

Skills and Abilities:

• Demonstrated analytical skills, maintain confidentiality with sensitive materials and communicate results to internal and external customers.
• Problem solving, analytical and decision-making skills.
• Self-motivated and directed with the ability to complete tasks with minimum supervision.
• Knowledge of Medicare processes and regulations.
• Knowledge of CPT, ICD-9, HCPC, and DRG coding.
• Knowledge of subscriber contract benefits, riders, plan requirements, and member obligations.
• Knowledge of HAP provider billing and coding requirements.
• Knowledge of provider pricing, claim payment, and adjustment processes.
• Excellent oral and written communication skills.
• Must have a high level of organizational planning and time management skills, complete follow-up and meet deadlines.
• Knowledge of insurance industry operations, health care benefits, structures, policies and procedures and medical coding.
• Familiarity with administrative and health care reimbursement data sources including standard code schemes (ICD 10, CPT, etc.).
• Demonstrated proficiency with Word and Excel.