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• MEDICARE CLAIMS PROCESSING EXP ***

JOB SUMMARY:
Under general direction, evaluates advanced level, moderately complex to complex, claims to determine the type and amounts of benefits payable. Performs all authorized duties in the processing of claims allocated to the assigned market consistent with all applicable company and departmental policies.

PRIMARY RESPONSIBILITIES:
1. Processes all advanced level claim transactions.
2. Accurately interprets, understands and applies Medicaid product contracts.
3. Meets or exceeds established quality and production standards.
4. Reviews and responds to Quality audit assessments and Action grams in a timely manner.
5. Works with other departments to resolve issues.
6. Adheres to company and departmental policies and procedures, as well as HIPAA regulations.
8. Prepares correspondence, responds to phone logs & contact logs, generates action grams, and completes projects for all markets.
9. Understands and implements appropriate claims processes and courses of action when adjudicating claims, to include new day claims, claims requiring research, claims requiring adjustments and claims associated with other health insurance coverage.
10. Receives all Coordinator of Benefits (COB) claims and information with COB indicators and processes claims according to coordination of benefits guidelines.
11. Interprets and communicates explanation of benefits (EOB) statements from other carriers to facilitate coordination of coverage.
12. Other duties as assigned.

EDUCATION AND EXPERIENCE:

Education
Required:
• High school diploma or GED.
Preferred:
• College Degree or some additional college level courses.

Years and Type of Experience
Required:
• Minimum of five years medical claims processing experience or, demonstrated proficiency as an AMERIGROUP Claims Analyst II.

Specific Technical Skills
Required:
• Intermediate to advanced level Microsoft Office skills.
• Advanced understanding of medical terminology, claims coding, and standard claims forms used for physician and hospital billings.
• Excellent reading comprehension and writing skills, to include the ability to apply step by step procedures to various situations and make logical decisions based upon general instructions.
• Understanding of intermediate/advanced level mathematical concepts and the use of a calculator (i.e. calculating percentages, use of multiplication and division in calculating appropriate benefits payable, use of 10-Key)
• Excellent analytical/problem Solving Skills.
• Knowledge of state guidelines and regulations applicable to Medicaid.

Certifications or Licensures
Required:
• N/A

Other:
Required:
• Strong interpersonal skills
• Demonstrates initiative; is proactive in problem resolution; ability to multitask and shift focus when needed
• Able to work independently and use reference material to resolve claims related questions.

SCOPE INFORMATION

1. Direct Reports: 0
2. Indirect Reports: 0
   Budgetary $ Responsibility: 0

PHYSICAL REQUIREMENTS:
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
• Ability to communicate both in person and/or by telephone.
• Data entry using repetitive motion

***MEDICARE CLAIMS PROCESSING EXP ***

JOB SUMMARY:
Under general supervision, evaluates advanced level claims to determine the type and amounts of benefits payable. Performs all authorized duties in the processing of claims allocated to the assigned market consistent with all applicable company and departmental policies.

PRIMARY RESPONSIBILITIES:
1. Responsible for processing all advanced level claim transactions.
2. Accurately interprets, understands and applies Medicaid contracts.
3. Meets or exceeds established quality and production standards.
4. Prepares and submits daily production reports in a timely manner.
5. Works with other departments to resolve issues.
6. Periodically runs system queries as necessary.
7. Adheres to company and departmental policies and procedures, as well as HIPAA regulations.
8. Responsible for preparing correspondence, maintenance of phone logs & contact logs, as well as project resolution for all markets.
9. Ability to understand and implement appropriate claims processes and courses of action when adjudicating claims, to include new day claims, claims requiring research, claims requiring adjustments and claims associated with other health insurance coverage.
10. Receive all Coordinator of Benefits (COB) claims and information with COB indicators and process claims according to coordination of benefits guidelines.
11. Ability to interpret and communicate explanation of benefits (EOB) statements from other carriers to facilitate coordination of coverage.
12. Other duties as assigned.

EDUCATION AND EXPERIENCE:

Education
Required: High school diploma or GED.
Preferred: College Degree or some additional college level courses

Years and Type of Experience
Required: Minimum of five years medical claims processing experience or, demonstrated proficiency as an AMERIGROUP Claims Analyst II.

Preferred:
Specific Technical Skills

Required:
• Intermediate to advanced level Microsoft Office skills.
• Advanced understanding of medical terminology, claims coding, and standard claims forms used for physician and hospital billings.
• Excellent reading comprehension and writing skills, to include the ability to apply step by step procedures to various situations and make logical decisions based upon general instructions.
• Understanding of intermediate/advanced level mathematical concepts and the use of a calculator (i.e. calculating percentages, use of multiplication and division in calculating appropriate benefits payable, use of 10-Key)
• Excellent analytical/problem Solving Skills.
• Knowledge of state guidelines and regulations applicable to Medicaid.

Preferred:
Certifications or Licensure

Required: NA
Preferred:

Other
Required:
• Strong interpersonal skills
• Demonstrates initiative; is proactive in problem resolution; ability to multitask and shift focus when needed
• Able to work independently and use reference material to resolve claims related questions.
Preferred:

SCOPE INFORMATION
Item Measure
• # Direct Reports NA
• # Indirect Reports NA
• Budgetary $ Responsibility NA
• Claim Payment Responsibility

PHYSICAL REQUIREMENTS
• Must be able to operate a computer, telephone and fax machine
• Data entry using repetitive motion
• Must be able to participate in meetings

In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.

AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.

How to apply: DO NOT use the Apply Online button. Please copy and paste the following link into your browser address bar:
http://amerigroup.contacthr.com/16536295