Analista de Reclamaciones I
Regular
Non-Exempt
GENERAL DESCRIPTION:
Responsible for analyzing and processing simple or non-complex professional and institutional claims when performing data entry, adjudicating, or declining payments, and/or requesting additional information following the benefits and requirements applicable up to the adjudication limit amount established in the current policy and procedure.
ESSENTIAL FUNCTIONS:
Receives, posts, records in the inventory, and archives the claims assigned to their work unit.
Cancels claims that have been worked on in their work unit.
Analyzes and processes simple or non-complex professional and institutional claims while performing data entry, adjudicating, or declining payments, and/or requesting additional information per the benefits and requirements applicable up to the maximum adjudication limit amount established in the current policy and procedure.
Performs data entry of claims, referrals, and CHRA.
Processes CMS-1500 and UB-04 claims according to the needs of the work unit and complies with the established processing and time rules.
Analyzes and corrects claims reports with errors in EDI systems, SourceCorp Queues, Applica, Assertus, Fastrieve, and other related programs.
Refers to analyzed claims that require support from other departments, as applicable, and processes claims that exceed the adjudication limit assigned to the next authorization level.
Processes no less than the average number of claims per hour established by MCS (which may vary from time to time), maintaining an applicable financial and processing accuracy as established in the current policy and procedure.
Keeps the personal productivity report updated and complies with it daily.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience:
Four-year high school diploma. Minimum two (2) years of experience in data entry in a Provider Call Center in the health insurance industry or a medical billing course.
OR
Education and Experience:
Two (2) years of university studies equivalent to 60 approved credits or an Associate's degree. Minimum of one (I) year of experience in data entry in a Provider Call Center in the health insurance industry or medical billing course.
"Proven experience may be replaced by previously established requirements."
Certifications/Licenses:
N/A
Other:
N/A
Languages:
Spanish –
Intermediate (writing, conversational, and comprehension)
English –
Intermediate (writing, conversational, and comprehension)
"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento
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