Position Overview: Review, analyze and adjust hospital and professional claims as necessary for Encounter resolution. Research Encounter Edit, identify trends and resolve root cause, which need a higher level of adjudicator expertise, EDI interpretation and decision making for Government lines of business. Contribute to establishing and/or revising claims research policies and procedures and look for ways to improve processes. Work with external vendors contracted for EDI transmissions. Participate in Encounter work groups, across departments and participate or lead other standing or ad hoc workgroups as needed.
Work Experience: Minimum five years claims adjudication experience with strong knowledge of Government requirements or equivalent work experience in a related health field. Coding experience is required. EDI knowledge is preferred.
Education, Certificates, Licenses: High school diploma or equivalent required.
Knowledge: Advanced proficiency in Microsoft Office Applications including Word and Excel. Intermediate knowledge of Government Programs (Medicare/Medicaid) structure, medical coding and medical terminology required. Knowledge of claims and provider network strongly encouraged. Intermediate understanding of EDI files and industry standard X12 specifications and requirements. Excellent Time Management, Critical Thinking and Research skills required.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.