Imagine Health
  • Cottonwood Heights, UT, USA
  • Hourly
  • Full Time

Summary

The Claims Processing Representative is responsible for assisting the Claims Specialist with pricing claims accurately and timely based on terms outlined in physician and hospital contracts. The Claims Processing Representative understands medical language including the various healthcare data types and the basics of health information technology to review priced claims.

 Duties and Responsibilities

  • Processes paper and electronic claims work queues, including HCFA 1500 and UB92, in accordance with company policies and procedures.
  • Audits already-priced claims for accuracy and due diligence.
  • Review contracts and apply contractual adjustments to the medical charges.
  • Answer phone and email inquiries from providers. Tracks inquiries to determine volume and type of issue and resolution times. Documents and saves communication in relation to claims. Monitors and maintains the inquiry queue.
  • Assists with setting up new groups and TPAs in the claims pricing engine.
  • Runs ad hoc reports as needed to answer any client and TPA activity questions related claims pricing.
  • Assists with claims pricing testing for any new rate schedule programming.
  • Adheres to client guidelines and escalate claims for management review when needed.
  • Build sustainable relationships and trust with providers and TPAs through open and interactive communication.
  • Collaborates with internal partners to enhance efficiencies and address operational issues.
  • Maintains superior customer service levels. Meets quality and quantity standards. Adheres to HIPAA guidelines and regulations.
  • Performs other duties as required.

 Education and Experience

  • High school Diploma / GED, college preferred
  • 3-5 years' experience in health information/medical records, or equivalent education/experience. Strong healthcare industry experience preferred.
  • 2-4 years' experience interpreting contracts to build reimbursement schedules
  • 1-2 years' claims processing or equivalent experience 

Skills and Abilities

  • In-depth knowledge and understanding of complex healthcare management concepts highly preferred.
  • Proficiency using Microsoft Word, Excel, Outlook, MS Access or other software applications to retrieve data, create spreadsheets, and reports.
  • Medical terminology familiarity preferred. 
  • EDI/837 experience preferred
  • Familiarity with Medicare requirements preferred
  • Claim auditing experience preferred
  • Ability to plan, organize and prioritize multiple projects to independently meet deadlines and complete tasks in an accurate manner.
  • Demonstrated analytical, problem solving and critical thinking skills, with experience in the evaluation of data integrity preferred.
  • Highly self-motivated and accountable
  • Excellent verbal and written communication skills.
  • Excellent organizational and interpersonal skills.
Imagine Health
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