SSM Health Hiring For Claims Representative, Health Plans at Madison, WI, United States Full Time

Job Description

Processes complex member and provider claims, utilizing advanced knowledge of the health plan products, medical terminology, and benefit options. Reviews claims for accuracy, completion and missing information. Determines coverage, confirms payment amounts, and submits for payment.
PRIMARY RESPONSIBILITIES

• Processes complex claims using the claims processing system and following department guidelines.
• Researches problem claim accounts, reversing and reprocessing claims as necessary.
• Reviews provider status to determine participating or nonparticipating, primary, referral, and correct reimbursement level, which may include repricing.
• Processes written benefits and claims inquiries from providers, escalating as appropriate.
• Processes provider appeals of claim determination to resolve or escalate as appropriate.
• Stays abreast of related regulatory, compliance and departmental updates to meet departmental metric requirements.
• Participates in team activities to identify problems and improve work processes and systems.
• Performs other duties as assigned.

EDUCATION

• High school diploma or equivalent

EXPERIENCE

• Experience: Two Years’ experience or one year experience as a Claims Associate

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.