Claims Reviewer
Job Tittle: Claims Reviewer Job ID: 75861 Location: Arizona - Remote What you will be doing:
- Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. CDST and policy keys, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations.
- Validates medical determinations through research of resources including regulatory manuals, computer files, and documentation.
- Prepares cases program payment or medical director review as indicated.
- Validates all appropriate data is supplied with program invoice.
- Reviews claim data for process improvements related to all aspects of claims payment.
- Ensures contract compliance for timelines regarding resolution of medical claims.
- Communicates effectively with management and peers.
- Consistently meets medical claims processing quotas.
- Identifies and reports any potential quality or fraud issues to management, Quality Management, or Program Integrity as needed.
- Provides support regarding clinical and coding questions.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
What you must have:
- High School Diploma or GED
- 2+ years of claims review experience
- Knowledge of all types of Medical claims review
Nice to have:
- Claim coding experience
- Knowledge of behavioral health claims review
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