|Employer:||Driscoll Health System
|Required Experience:||1 to 2 years
|Preferred Experience:||3 to 4 years
|Location:||3533 S. Alameda Corpus Christi 78411, TX, US
General Purpose of Job:
The Claims and Appeals Specialist is a certified medical coder that performs audits for correct coding and claims payments and oversees the claims appeal process for provider and member appeals. This position also investigates Coordination of Benefit (COB) claims. The Claims and Appeals Specialist I reports to the Director of Claims Oversight.
- General Duties:
- Maintains utmost level of confidentiality at all times.
- Adheres to hospital and DHP policies and procedures.
- Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
- Performs other duties as requested.
- Claims and Appeals Specialist I Duties and Responsibilities:
- Reviews claims appeals and makes recommendation/decision regarding reprocessing/denial of payment.
- Researches provider’s claims questions.
- Works closely with Provider Relations Representatives, to assist with provider claim issues.
- Provides incite to potential claims payment issues.
- Notifies Compliance Officer for DHP of potential fraud and abuse.
- Researches billing issues.
- Responds to providers regarding claims related issues.
- Coordinates coordination of benefit activities.
- Coordinates re-consideration of claims with DHP’s Third Party Claims Administrator
- Active member of bi-weekly claims meetings between DHP and DHP’s Third Party Claims Administrator
Education and/or Experience:
High school diploma or general education degree (GED); or one to three years related experience and/or training; or equivalent combination of education and experience.
One to three years experience with claims processing and coding.