The reviewer performs an initial review of claims, including HCFA 1500 and UB 92 claims.
The reviewer must meet or exceed production and quality standards and follow documented policies and procedures.
Performs initial review of all claim edits as directed. Completes or routes all reviews in accordance with time parameters established by The Health Plan.
Reviews each claim flag in sequence, totally completing one at a time in accordance with established criteria/payment guidelines.
Reports patterns of incorrect billing and utilization to the Benefit Services Unit Manager.
Advises supervisor of items that are unclear or that are not addressed in the established criteria/payment guidelines.
- Ability to follow written directions and work independently;
- Familiarity with Medical terminology, CPT and ICD-10 coding;
- Computer and typing experience;
- Experience in billing or physician office experience is preferred.