Researches and adjudicates all types of claims to ensure that protocols are followed with regard to provider contracts, member benefit schedules, established guidelines, and departmental policies and procedures.
· Processes & adjudicates the claims for accounts requiring multiple disciples in claims processing.
· Verifies claim information.
· Reviews referral information for verification of services rendered.
· Reviews eligibility for verification of member eligibility at time of service.
· Enters claims information into the claims adjudication system – when applicable.
· Validates results of claims after completion of pre-processor, adjudication & claims pricing.
· Corrects all system edits as a result of the 3 step claims process.
· Researches, reviews and adjudicates pended claims.
· Recognizes claims issues/problems, refers them to management and/or appropriate party, and assists in the review and implementation of resolution.
· Assures that claims are processed in accordance to member benefits, provider contact terms, network protocols, medical authorization and departmental guidelines.
· Maintains individual productivity reports on claims adjudication.
· Maintains production and quality standards established by Claims Department Management.