Verda Healthcare, Inc. has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are seeking a Claims Examiner II to join our growing company, which has many internal opportunities.
Are you ready to join a company that is changing the face of health care nationwide? Verda Healthcare, Inc. seeks people like you who value excellence, integrity, care and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc. and we will support you all the way.
Position Overview
The Claims Examiner II accurately reviews, researches, and analyzes professional, ancillary, and institutional inpatient and outpatient claims. Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines, and client groups’ and company policies and procedures.
This position reports to the Claims Manager as part of the Claims Department as part of Verda Healthcare, Inc.
Responsibilities:
- The Claims Examiner II accurately reviews, researches, and analyzes professional, ancillary, and institutional inpatient and outpatient claims
- Knowledge of CPT/HCPC and ICD-9/ICD-10 codes and guidelines
- Comprehensive knowledge of DMHC and CMS guidelines to accurately adjudicate Commercial and Medicare Advantage claims
- Comprehensive knowledge of various fee schedules and CMS prices for outpatient/inpatient institutional, ancillary and professional claims, including, but not limited to Medicare fee schedules, DRG, APC, ASC, SNF-RUG
- Ability to identify and report processing inaccuracies that are related to system configuration
- Process all types of claims, such as HCFA 1500, outpatient/inpatient UB92, high dollar claims, COB, and DRG claims
- Reviews processes and adjudicates claims for payment accuracy or denial of payment according to the Department’s policy and procedures
- Processes all claims accurately, conforming to quality and production standards and specifications in a timely manner
- Documents resolution of claims to support claim payment and/or decision
- Makes benefit determinations and calculations of type and level of benefits based on established criteria and provider contracts
- Understands and interprets health plan Division of Financial Responsibilities and contract verbiage
- Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines
- Adjudication of Commercial and Medicare Advantage claims
- Ability to prioritize, multitask, and manage claims assignment within department goals, regulatory compliance, and with minimal supervision
- Ability to make phone calls to Provider/Billing offices, when necessary, based on department guidelines
- Requests for additional information or follow up with provider for incomplete or unclean claims
- May resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or from claims incident/inquiries
- Identify root causes of claims, payment errors and report to Management
- Responds to provider inquiries/calls related to claims payment
- Collaborate with other departments and/or providers in successful resolution of claims-related issues
- Ability to effectively communicate with External and Internal teams to resolve claims issues
Minimum Qualifications
- Ability to interact in a positive and constructive manner
- Minimum of 3+ years’ experience in processing all types of professional, ancillary, and institutional claims in Managed Care
- Comprehensive knowledge of various fee schedules and CMS prices for professional, facility and ancillary claims
- Comprehensive knowledge of CPT, ICD-9 and ICD-10 codes, inpatient procedure coding, HCPCS, Revenue Codes, medical terminology and COB required
- Working knowledge of Claims Information systems
- Understands division of financial responsibility for determination of financial risk
- Type a minimum of 45 words per minute
- High School Diploma
Verda cares deeply about its employees’ future, growth, and well-being. Join our team today!
Job Type: Full-time
Benefits:
- 401(k)
- Paid time off
- Health insurance
- Dental Insurance
- Vision insurance
- Life insurance
Schedule:
- Full-time onsite
- Standard business hours Monday to Friday/weekends as needed
- Occasional travel may be required for meetings and training sessions.
Ability to commute/relocate:
- Reliably commute or planning to relocate before starting work (Required)
PHYSICAL DEMANDS
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
*Other duties may be assigned in support of departmental goals.