This position provides billing and claims management support to Alivi Specialty Networks and Business Process Outsourcing (BPO) Services. The Medical Claims Examiner ensures all claims comply with health plan, regulatory, contractual, compliance, and Alivi billing guidelines.
Responsibilities include accurate and timely adjudication of professional and institutional claims per state and federal regulations. Knowledge of insurance regulations, payment policies, and ability to communicate with payers to resolve claims is required. Skills in problem solving, benefit plan, and provider contract interpretation are essential.
The role involves analyzing, processing, researching, adjusting, and adjudicating claims using accurate procedure/revenue and ICD-10 Codes under correct provider contracts and member benefits. Responds to provider disputes timely and accurately, works with Clinical Review Board and Network Operations Team to resolve complex issues or disputes, adjudicates overturned claims, and generates correspondence to members, providers, and regulatory agencies.
Additional duties include assisting other departments with complex issues, processing overpayments and underpayments per guidelines and agreements, maintaining department claim edit rules, identifying trends for process improvement, and assisting in claims audits preparation.
High School diploma or equivalent. 3 years' experience in claims operations within healthcare insurance processing Medicare. Hands-on medical claims processing experience in insurance industry. Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees). Self-starter with ability to work independently and in teams. Strategic, analytical, process-oriented with critical thinking skills. Excellent written and verbal communication. Ability to manage multiple priorities. Strong problem-solving and follow-up abilities; adaptable to changing priorities. Works well under pressure. Proficient in Excel, PowerPoint, Word, Outlook. Knowledge of medical terminology and CPT, ICD-10, and Revenue Codes. Knowledge of Correct Coding (CCI) Edits. Experience preparing for Delegation Audits. Detailed knowledge of electronic billing processes and universal billing forms. Knowledge of CMS/ACHA Regulations desirable. Experience using Health Suite desirable. Certified Professional Coder (CPC) desirable.
Location
Miami, Florida, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 weeks ago