Job description

Full Job Description

At NTT DATA Services, we know that with the right people on board, anything is possible. The quality, integrity, and commitment of our employees are key factors in our company’s growth, market presence and our ability to help our clients stay a step ahead of the competition. By hiring the best people and helping them grow both professionally and personally, we ensure a bright future for NTT DATA Services and for the people who work here.

Must-have:
1-2 Years Facets Navigation Experience
2-3 Years of Claims processing experience
COB Experience a big plus

Workload - Medicaid

System: Facets

JOB DESCRIPTION:
The claims examiner is responsible for accurate and timely adjudication of claims for the Health Plans lines of business. Primary duties include analysis and resolution of claims, including coding principles, benefits, pricing, and potential third-party liability. The claims examiner must be able to work independently, effectively prioritizing work in a production environment that frequently changes to meet production standards and contractual requirements. The Claims Examiner must maintain production and inventory standards compliant with Claims Administration requirements. Success in this position will be based on the individual's ability to effectively prioritize work, identify, and resolve complex concerns in a professional manner, and work in a team environment to achieve and maintain production and inventory standards.

Role Responsibilities:

• Timely and accurate processing and adjudication of all types of claims from assigned workflow queues.
• Compliance with state, federal and contractual requirements to Claims Administration.
• Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications.
• Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review.
• Demonstrates a thorough knowledge of regulatory requirements, individual plan benefits, provider contracts, policies, and procedures for product assignment.
• Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate.
• Accurate and timely review of claim pricing to facilitate manual pricing as necessary, working with various Health Plan provider networks.
• Complete all mandatory claims training/refresher courses.
• Effectively communicates with members and providers verbally and in writing regarding claim issues including claim adjudication, subrogation, and overpayments or billing problems.
• Actively participates and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives.
• Complete all mandatory compliance and corporate training.
• Must be able to adapt to a changing work priorities and requirements and perform other duties as directed to support the overall functions of Claims Administration and support of staff without boundaries within the Plan.

Requirements

• High school diploma or equivalent required.
• Must have 3 years of relevant claim processing experience in insurance/healthcare industry(insurance, managed care or TPA Company) to support our clients.
• Possess high productivity and quality standards within a claims processing automation environment
• Knowledge of CPT, HCPC, ICD-9, ICD-10 codes
• Knowledge of HMO, PPO Medicare and Medicaid plans, as well as experience with Medicare Part D
• Knowledge of Medical terminology

The Company is an equal opportunity employer and makes employment decisions on the basis of merit and business needs. The Company will consider all qualified applicants for employment without regard to race, color, religious creed, citizenship, national origin, ancestry, age, sex, sexual orientation, genetic information, physical or mental disability, veteran or marital status, or any other class protected by law. To comply with applicable laws ensuring equal employment opportunities to qualified individuals with a disability, the Company will make reasonable accommodations for the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or an employee unless undue hardship to the Company would result.

Where required by law, NTT DATA provides a reasonable range of compensation for specific roles. The starting hourly range for this remote role is ($16.75-$16.75). This range reflects the minimum and maximum target compensation for the position across all US locations. Actual compensation will depend on several factors, including the candidate's actual work location, relevant experience, technical skills, and other qualifications. This position may also be eligible for incentive compensation based on individual and/or company performance.

This position is eligible for company benefits that will depend on the nature of the role offered. Company benefits may include medical, dental, and vision insurance, flexible spending or health savings account, life, and AD&D insurance, short-and long-term disability coverage, paid time off, employee assistance, participation in a 401k program with company match, and additional voluntary or legally required benefits.

Job Types: Full-time, Temporary

Pay: $16.75 per hour

Schedule:

• 8 hour shift
• Monday to Friday

Education:

• High school or equivalent (Required)

Experience:

• relevant healthcare claims processing: 3 years (Required)
• Facets: 2 years (Required)
• HMO, PPO, Medicare Part D: 1 year (Required)
• COB: 1 year (Required)

Work Location: Remote

smogtown13.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, smogtown13.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, smogtown13.com is the ideal place to find your next job.