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Claims Adjudicator

Confluence Health

Wenatchee, WA

Confluence Health

Accountable Care-OPS

Full Time

Day Shift

80

18948

Position Summary:

The Accountable Care Department is responsible for producing and managing information that assists healthcare providers in ensuring that the right care gets to the right patient at the right time. Currently, the department is responsible for working with specific Medicare Advantage, Medicaid, and Commercial populations to aid in this effort.

This position is responsible for timely and accurately processing of hospital and professional medical claims for the Medicaid membership serviced through the Accountable Care Department.

Essential Functions:

1.     Responsible for coordinating and supporting initiatives relative to the evaluation, processing, and handling of insurance claims.

2.     Acts as a liaison between the organization, its insurance provider and agents, claimants, and policy holders regarding the status and eligibility for coverage for all relevant claims.

3.     Manually reviews claims to make sure that billing requirements are met, updates accounts as necessary, answers inquiries, and makes recommendations for resolution.

4.     Understand various state and government billing rules and with the ability to identify claims that process incorrectly.

5.     Accurately run and work reports. Use critical thinking skills to submit new report requests as needed.

6.     Provide clear communication to providers and billers regarding payment, subrogation, refunds and claim inquiries.

7.     Productively manage the claims volume, and process check writes weekly.

8.     Responsible for participating in annual program audits.

9.     Provide clear communication to providers and billers regarding payment or claim inquiries.

10.  Ability to work independently, with minimal supervision, as well as participate as part of a team.

11.  Other duties as assigned.

Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.

Qualifications:

Required:

·          Associates degree or its equivalent work experience.

·          Proficient in letter writing skills and use of effective written communication skills to convey ideas or concepts.

·          Possesses intermediate computer skills (e.g., spreadsheets, word processing).

·          Knowledge of ICD-10, CPT coding, medical terminology, and insurance billing.

·          Strong attention to detail.

Desired:

·          Professional Medical (CPC) and/or Hospital (CPC-H) certification preferred.

·          Medical/hospital claims processing experience.

Who We Are: Confluence Health is an integrated healthcare delivery system that includes two hospitals and more than 40 medical specialties, to provide comprehensive medical care in North Central Washington. With over 270 physicians and 150 advanced practice clinicians, Confluence Health is the major medical provider between Seattle and Spokane. Our goal is to deliver high-quality, safe, compassionate, and cost-effective care close to home. Staying on the leading edge of healthcare innovation is important, so we invest in technology--to provide better care for our patients and allow our providers to operate at the highest level. Our Mission: We are dedicated to improving our patients' health by providing safe, high-quality care in a compassionate and cost-effective manner. Our Vision: To become the highest value rural healthcare system in the nation that improves health, quality of life, and is a source of pride to those who work here.