Claims Examiner III

Job Summary:
Review and investigate claims data entered to an on-line system to complete the adjudication process of more complex claims. Investigate and complete open or pended claims. Create adjustments to correct claim payments process.

The following job functions are included, but not limited to:

• Respond to complex service requests, adjusting claims as appropriate to resolve payment issues
• Processing all level of claims including COB, Hospital, Pharmacy, Skilled Nursing, and DME bills

Requirements and/or Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Detailed knowledge of general claims processing principles, HCFA claims coding, and UB-92 claims coding, based on at least 3 years experience in claims processing, customer service, or medical billing, preferably in a managed care environment
• Knowledge of IDX IS plus
• Ability to apply general processing procedures and specific guidelines to claims data to make valid decisions on claims liability
• Achieve stringent quality goals of 98% statistical accuracy and 99% financial accuracy to contribute to achieving client performance expectations. Expected to meet production standards as well
• Ability to analyze complex claims problems and accurately resolve payment issues
• Ability to work well with management and team members to contribute to the achievement of departmental goals
• Availability to work overtime, as needed

Education and/or Experience:

• High school diploma or equivalent

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HMO Risk Collector

Job Summary:
Seeking an energetic, organized, and experienced individual to be a Claims/HMO Risk Collector. The Claims/HMO Risk Collector will be responsible for contacting providers and healthplans to get status on overpayment requests and cap deduction status. The Claims/HMO Risk Collector will also be responsible for analyzing reports and collecting past due overpayment accounts. Furthermore, this individual will be responsible for special Claims Recovery projects.

The following job functions are included, but not limited to:

• Actively make collection calls on current and past due overpayment accounts
• Provide analysis and reports on recovery status
• Analyze overpayment letters and payment accounts to providers
• Correspond with health insurance companies in regard to cap deductions
• Provide weekly and monthly Recovery reports to Manager

Requirements and/or Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The ability to work independently with minimal supervision
• Proficient in Excel to include the ability to create and update an Excel spreadsheet for purposes of tracking and reporting
• Excellent verbal and written communication skills with emphasis on Collections
• Medical Claims processing or Claims related experience
• Knowledge of AB1455 and CMS guidelines

Education and/or Experience:

• A High School Diploma or Equivalent BS/BA preferred
• Two years of college or comparable or equivalent to 2 years within healthcare industry
• One to two years experience in collections
• Thorough knowledge of PC usage is required

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If you are interested in any of the above positions, please send your resume and salary history to: hr@prospectmedical.com. Also please include the job title in the subject line.