Claims reviewer job description
Updated March 14, 2024
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Example claims reviewer requirements on a job description
Claims reviewer requirements can be divided into technical requirements and required soft skills. The lists below show the most common requirements included in claims reviewer job postings.
Sample claims reviewer requirements
- Bachelor's degree in related field
- Previous experience in claims review
- In-depth knowledge of insurance regulations
- Familiarity with medical terminology
- Proficiency in relevant software
Sample required claims reviewer soft skills
- Strong communication skills
- Excellent analytical abilities
- Attention to detail and accuracy
- Organizational and time management skills
- Ability to work independently
Claims reviewer job description example 1
Kaiser Permanente claims reviewer job description
Ensures the integrity of outside medical payments for the organization by verifying the accuracy of data-entered information and by reviewing claims-related information and invoice adjudication/payment for compliance with contract terms and according to department/regional policy and procedures. Conducts research, assists with problem resolution within specialized areas such as Medicare, Multiplan, Workers' Compensation, Coordination of Benefits and Third Party liability. May provide education and feedback to staff involved in related processes and may assist with recovery of funds and response to appeals.
Essential Functions:
- Analyzes referrals and claims information for accuracy according to established guidelines.
- Provides education, feedback and reports as applicable.
- Assists with tracing sources of inaccuracies.
- Reports and proposes remedial action to appropriate manager.
- Prepares detailed analysis of claims activity and submits reports/findings as requested.
- Maintains records of special processing payment adjustments and check requests.
- Works with other departments as a resource regarding all aspects of Outside Medical Claims.
- Researches and provides reports as requested.
- Reviews processing of outside medical payments on a continuous basis.
- Audits and verifies documentation, approvals and accurate coding of provider service and accounting data.
- Monitors and coordinates special transactions, e.g., check adjustments and credits.
- Performs data analysis for outside medical payments and provides performance feedback.
- Formats and prepares statistical reports to assist with budget monitoring and financial analysis.
- Reviews and recommends accurate recording of outside medical utilization data by testing for appropriate and consistent invoice coding.
- Prepares special comprehensive reports as indicated or requested by management.
- May provide education and feedback to staff involved in related processes.
- May assist with recovery of funds and providing timely response to appeals.
Basic Qualifications:
- Two (2) years of claims analysis and medical billing experience.
- High School diploma or GED required.
- Knowledge of CPT, ICD, RBRVS, and other applicable references.
- Familiarity with outside medical systems and claims processing/adjudication processes.
- Demonstrated knowledge of both mainframe and personal computer programs.
- Excellent mathematical, written and verbal skills and demonstrated medical terminology competence.
- Demonstrated ability to act under limited supervision.
- Ability to understand, develop and implement procedures.
Preferred Qualifications:
- Bachelor's degree in accounting, audit, finance or a related field preferred.
COMPANY: KAISER
TITLE: Claims Reviewer ASC
LOCATION: Bakersfield, California
REQNUMBER: 1108518
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
Essential Functions:
- Analyzes referrals and claims information for accuracy according to established guidelines.
- Provides education, feedback and reports as applicable.
- Assists with tracing sources of inaccuracies.
- Reports and proposes remedial action to appropriate manager.
- Prepares detailed analysis of claims activity and submits reports/findings as requested.
- Maintains records of special processing payment adjustments and check requests.
- Works with other departments as a resource regarding all aspects of Outside Medical Claims.
- Researches and provides reports as requested.
- Reviews processing of outside medical payments on a continuous basis.
- Audits and verifies documentation, approvals and accurate coding of provider service and accounting data.
- Monitors and coordinates special transactions, e.g., check adjustments and credits.
- Performs data analysis for outside medical payments and provides performance feedback.
- Formats and prepares statistical reports to assist with budget monitoring and financial analysis.
- Reviews and recommends accurate recording of outside medical utilization data by testing for appropriate and consistent invoice coding.
- Prepares special comprehensive reports as indicated or requested by management.
- May provide education and feedback to staff involved in related processes.
- May assist with recovery of funds and providing timely response to appeals.
Basic Qualifications:
- Two (2) years of claims analysis and medical billing experience.
- High School diploma or GED required.
- Knowledge of CPT, ICD, RBRVS, and other applicable references.
- Familiarity with outside medical systems and claims processing/adjudication processes.
- Demonstrated knowledge of both mainframe and personal computer programs.
- Excellent mathematical, written and verbal skills and demonstrated medical terminology competence.
- Demonstrated ability to act under limited supervision.
- Ability to understand, develop and implement procedures.
Preferred Qualifications:
- Bachelor's degree in accounting, audit, finance or a related field preferred.
COMPANY: KAISER
TITLE: Claims Reviewer ASC
LOCATION: Bakersfield, California
REQNUMBER: 1108518
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
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Claims reviewer job description example 2
Northern Lights claims reviewer job description
Northern Light Health
Department: Patient Financial Services
Position is located: Cianchette Professional Blding
Work Type: Full Time
FTE: 40 Hours per Week
Work Schedule: 8:00 AM to 4:30 PM
Summary:
This position is responsible for leading the claims submission operations of the EMHS Patient Account Services in a Centralized Business Office environment. This position is responsible for the claim processes in accordance with regulatory and contractual obligations. This position requires a thorough understanding of the requirements of the Centers for Medicare & Medicaid Services (CMS) claim forms; CMS-1500 and CMS-1450 (UB04). In addition, this position is accountable that all claim responsibilities are in accordance with policies, procedures, and applicable laws; including metrics related to productivity and quality. This position leads a team of Claim Specialists that analyze and take corrective action on claims to ensure an optimum revenue cycle workflow.
Responsibilities:
People
· Provide employee performance feedback to the Supervisor.
· Ensure employees are adequately trained in the area of claims submission in accordance with regulatory and contractual obligations.
Service
· Work closely by way of problem solving with peers and other revenue cycle departments to address payer claim issues or changes that directly impact the accounts receivable.
Quality
· Review and trend unworked claims and in collaboration with Supervisor implement corrective action plans.
· Review the held claims report by payer each day: escalate aged claims and address issues/trends with the claims on hold in error.
· Ensure departmental procedures and performance standards are in place and adhered to consistently.
Finance
· Review and trend claim edits including electronic rejections by payer and communicate summary of findings to management.
· Monitor inflow of claims each day; assess volumes, communicate issues, and, when necessary, restructure the workflow of the Claim Specialists.
· Assist in the development of team goals and objectives that adhere to the department and EMHS's financial performance objectives.
· Ensure assigned discharged not final billed (DNFB) and final billed not submitted (FBNS) claims are not delinquent and are escalated timely.
+ Advises the Supervisor of claim issues which may require attention, and makes recommendations to changes needed.
· Provide key and relevant information to the Supervisor for the fiscal month summary of changes in the accounts receivable.
Growth
· Maintain the knowledge of payer billing policies; attend local, regional, or national conferences/seminars to remain current.
· Certified Revenue Cycle Specialist certificate within two years of employment.
Community
· Demonstrate departmental desire to provide community benefits by way of charitable events or contribution outside the four walls of the department.
Competencies and skills:
Essential:
* 2+ years of relative work experience required.
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Ability to understand the language used to precisely describe the human body including its components, processes, conditions affecting it, and procedures performed upon it.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
Working conditions:
Essential:
* Prolonged periods of sitting.
Department: Patient Financial Services
Position is located: Cianchette Professional Blding
Work Type: Full Time
FTE: 40 Hours per Week
Work Schedule: 8:00 AM to 4:30 PM
Summary:
This position is responsible for leading the claims submission operations of the EMHS Patient Account Services in a Centralized Business Office environment. This position is responsible for the claim processes in accordance with regulatory and contractual obligations. This position requires a thorough understanding of the requirements of the Centers for Medicare & Medicaid Services (CMS) claim forms; CMS-1500 and CMS-1450 (UB04). In addition, this position is accountable that all claim responsibilities are in accordance with policies, procedures, and applicable laws; including metrics related to productivity and quality. This position leads a team of Claim Specialists that analyze and take corrective action on claims to ensure an optimum revenue cycle workflow.
Responsibilities:
People
· Provide employee performance feedback to the Supervisor.
· Ensure employees are adequately trained in the area of claims submission in accordance with regulatory and contractual obligations.
Service
· Work closely by way of problem solving with peers and other revenue cycle departments to address payer claim issues or changes that directly impact the accounts receivable.
Quality
· Review and trend unworked claims and in collaboration with Supervisor implement corrective action plans.
· Review the held claims report by payer each day: escalate aged claims and address issues/trends with the claims on hold in error.
· Ensure departmental procedures and performance standards are in place and adhered to consistently.
Finance
· Review and trend claim edits including electronic rejections by payer and communicate summary of findings to management.
· Monitor inflow of claims each day; assess volumes, communicate issues, and, when necessary, restructure the workflow of the Claim Specialists.
· Assist in the development of team goals and objectives that adhere to the department and EMHS's financial performance objectives.
· Ensure assigned discharged not final billed (DNFB) and final billed not submitted (FBNS) claims are not delinquent and are escalated timely.
+ Advises the Supervisor of claim issues which may require attention, and makes recommendations to changes needed.
· Provide key and relevant information to the Supervisor for the fiscal month summary of changes in the accounts receivable.
Growth
· Maintain the knowledge of payer billing policies; attend local, regional, or national conferences/seminars to remain current.
· Certified Revenue Cycle Specialist certificate within two years of employment.
Community
· Demonstrate departmental desire to provide community benefits by way of charitable events or contribution outside the four walls of the department.
Competencies and skills:
Essential:
* 2+ years of relative work experience required.
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Ability to understand the language used to precisely describe the human body including its components, processes, conditions affecting it, and procedures performed upon it.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
Working conditions:
Essential:
* Prolonged periods of sitting.
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Claims reviewer job description example 3
Children's Home Society of Florida claims reviewer job description
Since opening our doors in 1902, CHS became a part of Florida's history.
CHS has been committed to growing and evolving to provide the right services and solutions to address the needs of children and families throughout the changing times. Every day, our team works with parents and kids to empower them and encourage them. With innovative technology solutions and a dedicated, experienced team throughout the state, we're changing the face of foster care and positively impacting children and families' lives for generations to come.
Join our team to continue to do good and create history serving Florida's children and families!
The Behavioral Health Claims Reviewer facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation for the purposes of ensuring compliance with Medicaid/AHCA/MCO regulations and guidelines in order to expedite appropriate reimbursement. Overall, the Behavioral Health Claims Reviewer contributes to the CHS high performance culture by exhibiting our values and providing quality results that position CHS as the leader in delivering proactive behavioral health, case management, community and early childhood solutions for children and families.
WHY JOIN CHS?
+ Uplifting mission-driven work culture
+ Make an impact in your community and become a part of Florida's history!
+ Growth and professional development opportunities
+ Great benefits package, including generous paid time off and holidays
Primary Job Functions
1. Monitor and evaluate the quality and compliance of behavioral health service documentation
+ Audit Medicaid, contract and commercial insurance claims documentation submitted by individual providers to determine the sufficiency of evidence of compliance.
+ Review billing documentation for compliance with all regulatory requirements, policies, procedures and payer standards in a timely and accurate manner.
+ Determine if billing documentation information resulted in an accurate payment determination.
+ Report on information gathered during record reviews for training, reporting, compliance, and quality purposes.
+ Provide information regarding correction rates, compliance rates, amount of unbilled services located, amount of corrections completed, and amount of services re-billed per provider site.
+ Relay review findings to service staff and track the completion of suggested corrections when appropriate,
+ Assist with review bills for suspected falsification and misrepresentations of services provide as well as other irregularities by CHS team members or contracted providers.
+ Protect clients and CHS by keeping claims information and PHI confidential.
2. Contribute to a positive, engaging work environment.
+ Develop a strong knowledge base and stay current on job-related issues and trends.
+ Participate actively in departmental meetings, training and education, as well as the quality process.
+ Comply with CHS's code of conduct, policies, procedures and other obligations.
+ Assist with training other team members and providing back up when necessary.
+ Pick up projects on the fly; perform other duties as assigned from time to time.
+ Demonstrate the CHS Common Bond values in the performance of all job duties.
Job Qualifications
Education, Licenses & Certifications:
+ Bachelor's degree in Health Sciences, Health Information, Business, or Social Sciences related field from an accredited university, required.
Experience:
+ Two years' experience in maintaining medical records, compliance/auditing, and/or Medicaid, required
+ Experience working with an electronic medical records, preferred
Competencies
Knowledge of:
+ Compliance | Medicaid | Behavioral Health | Florida Statute
Skills and Proficiency in:
+ Planning, organization and time management, oral & written communication
+ Interpersonal Relationship Building, Collaboration, Teaming
+ Computer systems and MS Office, including Word, Excel and Outlook
Ability to:
+ Act in accordance with coverage under the various Florida Behavioral Health Medicaid services as they relate to services, documentation requirements, claims, and billing.
+ Read, understand and apply Medicaid and other regulatory requirements.
+ Perform repetitive tasks for extended periods of time.
+ Commit to providing high customer satisfaction with positive service delivery results
+ Be energetic, passionate and adaptable with a deep commitment to social service, empathy for children and families and a positive approach to embracing and managing change.
+ Perform at a high level of autonomy, with general supervision.
+ Perform under strong demands in fast-paced, diverse, sometimes ambiguous environments.
+ Handle highly stressful, sensitive situations; maintain confidentiality and professional boundaries.
+ Meet critical deadlines, while maintaining attention to detail, accuracy and quality
+ Demonstrate the behaviors of our CHS Common Bond Values.
Together, good can be done.
ID: 2022-8072
Travel Range: Countywide
Travel: Remote
External Company Name: Childrens Home Society of Florida
Street: 5766 S Semoran Blvd
CHS has been committed to growing and evolving to provide the right services and solutions to address the needs of children and families throughout the changing times. Every day, our team works with parents and kids to empower them and encourage them. With innovative technology solutions and a dedicated, experienced team throughout the state, we're changing the face of foster care and positively impacting children and families' lives for generations to come.
Join our team to continue to do good and create history serving Florida's children and families!
The Behavioral Health Claims Reviewer facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation for the purposes of ensuring compliance with Medicaid/AHCA/MCO regulations and guidelines in order to expedite appropriate reimbursement. Overall, the Behavioral Health Claims Reviewer contributes to the CHS high performance culture by exhibiting our values and providing quality results that position CHS as the leader in delivering proactive behavioral health, case management, community and early childhood solutions for children and families.
WHY JOIN CHS?
+ Uplifting mission-driven work culture
+ Make an impact in your community and become a part of Florida's history!
+ Growth and professional development opportunities
+ Great benefits package, including generous paid time off and holidays
Primary Job Functions
1. Monitor and evaluate the quality and compliance of behavioral health service documentation
+ Audit Medicaid, contract and commercial insurance claims documentation submitted by individual providers to determine the sufficiency of evidence of compliance.
+ Review billing documentation for compliance with all regulatory requirements, policies, procedures and payer standards in a timely and accurate manner.
+ Determine if billing documentation information resulted in an accurate payment determination.
+ Report on information gathered during record reviews for training, reporting, compliance, and quality purposes.
+ Provide information regarding correction rates, compliance rates, amount of unbilled services located, amount of corrections completed, and amount of services re-billed per provider site.
+ Relay review findings to service staff and track the completion of suggested corrections when appropriate,
+ Assist with review bills for suspected falsification and misrepresentations of services provide as well as other irregularities by CHS team members or contracted providers.
+ Protect clients and CHS by keeping claims information and PHI confidential.
2. Contribute to a positive, engaging work environment.
+ Develop a strong knowledge base and stay current on job-related issues and trends.
+ Participate actively in departmental meetings, training and education, as well as the quality process.
+ Comply with CHS's code of conduct, policies, procedures and other obligations.
+ Assist with training other team members and providing back up when necessary.
+ Pick up projects on the fly; perform other duties as assigned from time to time.
+ Demonstrate the CHS Common Bond values in the performance of all job duties.
Job Qualifications
Education, Licenses & Certifications:
+ Bachelor's degree in Health Sciences, Health Information, Business, or Social Sciences related field from an accredited university, required.
Experience:
+ Two years' experience in maintaining medical records, compliance/auditing, and/or Medicaid, required
+ Experience working with an electronic medical records, preferred
Competencies
Knowledge of:
+ Compliance | Medicaid | Behavioral Health | Florida Statute
Skills and Proficiency in:
+ Planning, organization and time management, oral & written communication
+ Interpersonal Relationship Building, Collaboration, Teaming
+ Computer systems and MS Office, including Word, Excel and Outlook
Ability to:
+ Act in accordance with coverage under the various Florida Behavioral Health Medicaid services as they relate to services, documentation requirements, claims, and billing.
+ Read, understand and apply Medicaid and other regulatory requirements.
+ Perform repetitive tasks for extended periods of time.
+ Commit to providing high customer satisfaction with positive service delivery results
+ Be energetic, passionate and adaptable with a deep commitment to social service, empathy for children and families and a positive approach to embracing and managing change.
+ Perform at a high level of autonomy, with general supervision.
+ Perform under strong demands in fast-paced, diverse, sometimes ambiguous environments.
+ Handle highly stressful, sensitive situations; maintain confidentiality and professional boundaries.
+ Meet critical deadlines, while maintaining attention to detail, accuracy and quality
+ Demonstrate the behaviors of our CHS Common Bond Values.
Together, good can be done.
ID: 2022-8072
Travel Range: Countywide
Travel: Remote
External Company Name: Childrens Home Society of Florida
Street: 5766 S Semoran Blvd
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Updated March 14, 2024
Updated March 14, 2024