Medicare Claims Representative

About This Role

Process Medicare claims from receipt through resolution, ensuring timely and accurate resolution in accordance with policies and regulatory requirements. This role maintains high standards for quality and customer service.

Responsibilities

• Process Medicare claims from receipt through resolution
• Review complex Medicare Part A claims, applying federal and internal guidelines
• Handle complex adjustments involving multiple admissions and patient complaints
• Communicate with internal departments, healthcare providers, and members to clarify claim issues
• Interact with providers by phone to resolve pending claim problems
• Assist the claims department in meeting CMS performance metrics and quality/quantity standards
• Support the claims department and provide back-up for completing staff responsibilities
• Keep up to date with changes in regulations, coding standards, and plan policies
• Meet requirements of Federal Privacy Act, ISO 9000, Freedom of Information, and WPS conflict of interest and confidentiality

Requirements

• High School Diploma or GED or equivalent experience
• 1+ years of experience in hospital, clinic and/or medical office billing
• 1+ years of post-high school education or coursework in insurance or medical-related studies
• 1+ years of experience in a position using computer, keyboarding, and customer communications
• Demonstrated proficiency in data entry with a strong ability to maintain focus and accuracy
• Ability to multitask, prioritize, problem-solve, and effectively adapt to a fast-paced environment
• Ability to work independently and meet quality and production standards

Qualifications

• High School Diploma or GED or equivalent experience
• 1+ years of experience in hospital, clinic, and/or medical office billing, 1+ years of post-high school education or coursework in insurance or medical-related studies, and 1+ years of experience in a position using computer, keyboarding, and customer communications.

Nice to Have

• Previous health/Medicare adjudication experience
• Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims
• Familiarity with medical terminology, procedure and diagnosis codes

Skills

* Required skills

Benefits