The Claims Review Representative 3 partners with professional staff on pre-screening review by applying guidance, and making an appropriate decision which may include interpretation of provider information or data. Decisions are typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Fully Bilingual. Must be able to speak, read and write in the English language without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English
1 – 3 years of technical experience
3 years of strong and proven experience with processing and adjudicating medical claims
Proficiency in Microsoft Office applications including Word, Excel and Outlook
Working knowledge of computers or a demonstrated technical aptitude
Ability to quickly learn new systems
Ability to manage and prioritize tasks based on business need
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Associate’s or Bachelor’s Degree
Knowledge with CPT, ICD9, and ICD10 terminology/codes
CAS and/or CCP experience
CIS/ CIS Pro experience
Scheduled Weekly Hours