WI3668681

1

Vocational Degree

Associate Degree

Unspecified

40

JOB REQUIREMENTS: Overview Claims Adjudicator Examiner, MercyCare
Insurance, Days, 80 Hrs/ 2 wks Location: MercyCare Building; Janesville,
WI Analyzes claims to determine extent of insurance carrier\'s liability
in accordance with policy provisions regarding third party liabilities.
Training of adjudicators and processors as assigned by manager. Respond
to questions from adjudicators and processors. Create Standard Operating
Procedures for new products as assigned by management. Review and update
existing Standard Operating Procedures on a yearly basis or as needed
upon upgrades to the claims payment system. Assist adjudicators and/or
processors as needed in order to assure claims are completed within
standards. Performs other duties as assigned. Responsibilities
Investigate all non-standard claim problems (25%) Investigates for COB
and determine the primary payer (25%) Investigate and process adjustment
requests (25%) Adjust claim payments resulting from duplicate payments,
incorrect payee, etc. Recover expended funds for managed care plans
System documentation of investigation results Training of Coordination
of Benefits claim processing for new claims examiners Respond to
questions from claim processors and examiners Training of processors and
examiners as assigned by department coordinator Enter and process paper
COB claims based on alpha split Investigate claims for possible third
party liability through independent investigation and our legal
department. This is achieved through review of claims history and
medical records. May also involve direct telephone contact or written
correspondence with doctors, lawyers, members or others involved to
resolve coverage questions. Investigate non participating provider
claims to determine if a discount can be obtained. Must understand all
system edits and resolve correctly Assist other partners by continuously
training, education or whatever means necessary to assure compliance
with regulatory requirements and internal standards. Yearly review of
standard operating procedures to assure compliance with regulatory
requirements, contracts and internal standards. Create new standard
operation procedures for new products or procedures. May be asked to
audit partners for accuracy in entry and adjudication. May be asked to
lead group in process improvement plans based on member complaints or
audit results. May be asked to assist in claims data entry of claims
other than those COB claims directly assigned based on alpha split.
Education and Experience Associate degree in a health or business field
or at least 5 years of experience in claims adjudication required.
Medical terminology helpful, but not required. Extensive knowledge of
Coordination of Benefits rules required. ICD-10 and CPT-4 knowledge\...
For full info follow application link. EOE&AA/M/F/Vet/Disabled. Mercy is
an equal employment opportunity employer functioning under Affirmative
Action Plans. \*\*\*\*\* APPLICATION INSTRUCTIONS: Apply Online:
ipc.us/t/70F988542CE74708