Claims Specialist - Allied Advocate
Claims Specialist - Allied Advocate
Allied Benefit Systems
United States
See who Allied Benefit Systems has hired for this role
CLAIMS SPECIALIST
Position Summary
Determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s).
Essential Functions
Ability to work with computer-based programs for extended periods of time.
WORK ENVIRONMENT
Remote
Position Summary
Determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s).
Essential Functions
- Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
- Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
- Contact providers to negotiate discounts.
- Log claims negotiated in Access database and create weekly summary reports.
- Review and understand the terms and conditions of each clients’ customized plans.
- Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
- Request, review and analyze any physician notes, hospital records or police reports.
- Consult with other entities who can offer additional evaluation of a claim.
- Process claims in the QicLink System.
- Review, analyze and add applicable notes to the QicLink System.
- Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
- Review billed procedure and diagnosis codes on claims for billing irregularities.
- Analyze claims for billing inconsistencies.
- Review and analyze specific procedure and diagnosis codes for medical necessity.
- Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
- Review Suspended Claim Reports and follow up on open issues.
- Assist and support other team members as needed and when requested.
- Attend continuing education classes as required, including but not limited to HIPAA training.
- High School Diploma, College and Advanced Degrees Preferred
- Continuing education in all areas affecting group health and welfare plans is required.
- All applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-10 coding terminology.
- Applicants must have a minimum of 5 years of medical claims analysis experience (including dental and vision claims analysis).
- Detail oriented with strong organizational skills
- Ability to make independent determinations
- Job Knowledge
- Time Management
- Accountability
- Communication
- Initiative
- Customer Focus
Ability to work with computer-based programs for extended periods of time.
WORK ENVIRONMENT
Remote
-
Seniority level
Mid-Senior level -
Employment type
Full-time -
Job function
Legal -
Industries
Insurance
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