The Claims Review Coordinator is responsible for the investigation, documentation and resolution of denied claims in compliance with State/Federal law, rules, and guidelines. The Claims Review Coordinator will perform research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.
This position interacts with the Health Plan staff, Plan participants, business managers, health care providers, medical insurance companies and related governmental agencies, and medical consultants. In addition to daily interaction with the Department Manager and Assistant Manager, this position also interacts with Executive Management whenever necessary.
ESSENTIAL FUNCTIONS:
Work independently using discretion and independent judgment under the general supervision of the department manager and within broad parameters of policy established by management:
Write determination letters regarding the outcome of non-clinical reviews/claim denials and send to the applicable participant/provider. Correspond with participants and providers via email and telephone.
Research incoming correspondence related to claim denials and determine what next steps need to be taken.
Assist with research to advise management on medical claims issues and assist with developing guidelines for use by the examiners or Participant Services Representatives when necessary.
Assist Appeals Coordinator with preparation of Benefits Committee appeal cases.
Develop guidelines for examiners to use in evaluating whether certain types of claims may require review and other medical claims issues.
Requirements
Have knowledge of group health plan philosophy and Department of Labor health claim regulations.
Knowledge of medical benefits, medical terminology and coding, and coordination of benefits rules.
Knowledge of basic math related to claims adjudication.
Excellent analytical and research abilities.
Compensation: $24/hr to $27/hr. Exact compensation may vary based on several factors, including skills, experience, and education. Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law