Medical Claims Eligibility Specialist II-Hybrid

Job Description

Job Description

MET Healthcare Solutions is seeking a Medical Claims Eligibility Specialist II to join our fast-paced organization. The Medical Claims Eligibility Specialist II will be responsible for analyzing level II claims information to determine eligibility in the dispute resolution process in accordance with established federal regulations and company policies and procedures.

Responsibilities of the Medical Claims Eligibility Specialist II may include but are not limited to:

· Analyze Explanation of Benefits (EOB) and payment remittance documents submitted by healthcare providers and insurance carriers to determine which level II claims are eligible for the dispute resolution process.

· Compose correspondence in accordance with regulatory requirements (and internal policies in procedures) in a clear, concise, and grammatically correct manner.

· Communicate (via email) with healthcare providers and health plans to obtain information necessary to determine the eligibility of the claims. 

· Relay the status of all claim submissions utilizing multiple different operating systems.

· Stay up to date on industry specific regulations, ensuring that appropriate strategies are in place.

· Maintain electronic files for all claims determined eligible.

These responsibilities are a condensed list of the full scope of the job description and are subject to change depending on the company’s demand.

· Experience reviewing all types of medical claims, EOBs, and payment remittances (e.g. HCFA 1500, Outpatient/Inpatient UB92, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).

· Understanding of insurance reimbursement rules.

· Ability to work at a high level and display high attention to detail.

· Ability to work across multiple operating systems.

· Ability to maintain confidentiality and professionalism in difficult situations.

· Strong written and verbal communication skills with the ability to explain reasoning effectively.

This Medical Claims Eligibility Specialist II position is offered as a hybrid position (after in office training) to those candidates that meet all the position requirements and continue to meet the daily expectations.

This is a full-time position, Monday-Friday from 8am-5pm. Please only apply if you are able to meet these requirements weekly.

 

Education:

• Bachelor's (Required)

Experience:

• Healthcare Claims Analysis: 2 years (Required)

License/Certification:

• Billing and Coding Certification (Preferred)

 

Company Description

A healthcare management group, URAC-accredited as an independent review organization (IRO). Over 20 years of experience helping control costs, and mitigate regulatory compliance by providing superior administrative and medical expert services to improve the quality of healthcare functions nationwide. Making a difference in healthcare.

Company Description

A healthcare management group, URAC-accredited as an independent review organization (IRO). Over 20 years of experience helping control costs, and mitigate regulatory compliance by providing superior administrative and medical expert services to improve the quality of healthcare functions nationwide. Making a difference in healthcare.