We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI and WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services. Applies clinical, coding, and processing knowledge to conduct review and process claims. Compiles information necessary to prepare cases program payment. Ensures adherence to program benefits as authorized. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed. Advises clinical and non-clinical staff on claims and coding questions.

Education and Experience

Required:

3+ years of claims review experience If supporting TRICARE contract, must be a U.S. Citizen If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation Knowledge of all types of Medical claims review Preferred:

Claim coding experience Government health care claims experience

Key Responsibilities

Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. CCI Fine-a-Code, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations. Validates medical determinations through research of resources including regulatory manuals, computer files and documentation. Prepares cases program payment or medical director review as indicated. Validates all appropriate data is supplied with program invoice. Reviews claim data for process improvements related to all aspects of claims payment. Ensures contract compliance for timelines regarding resolution of medical claims. Communicates effectively with management and peers. Consistently meets medical claims processing quotas. Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity as needed.

Performs invoice review and resolution. Works with VA on Invoice Reconciliation. Acts as a subject matter expert and assists supervisor and manager with questions from claims reviewer. Provides telephone customer assistance to government employees, Veterans, providers and regional managers. Provides support regarding clinical and coding questions. Performs other duties as assigned. Regular and reliable attendance is required.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback. Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation. Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required. High Intensity Environment: Ability to function in fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract. Working knowledge of behavioral health claims adjudication principles.

Working Conditions

Working Conditions:

Favorable working conditions in a climate-controlled office space Must be available to cover any work shift Works within an office environment with minimal travel required Extensive computer work with prolonged sitting

Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $58,837.50- 62,106.25 depending on experience