Claims Reviewer - VA & TW Internal Claims Inquiries

Position Overview

Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services, as it relates to claims inquiry, resolution, audit, and related functions. Applies clinical, coding, and processing knowledge to conduct review of claims. Validates and compiles information necessary to prepare cases for program payment. Ensures adherence to Government contract requirements. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed. Advises clinical and non-clinical staff on claims and coding questions.

Required Qualifications

• High School Diploma or GED
• 2 years of claims review experience
• Knowledgeable in medical, institutional, and behavioral health claims processes
• Demonstrated ability to communicate effectively, both verbally and in writing
• Experience using MS Word, Excel, and Office

Preferred Qualifications

• Government claims experience
• Claims coding certification or equivalent experience
• Intermediate proficiency with MS Office suite

Key Responsibilities

• Validates claim outcomes for accuracy and routes for adjustment, as necessary.
• Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.
• Validates claims submission details against systems data.
• Adheres to all desktop procedures for assigned function.
• Identifies and appropriately communicates processing discrepancies or trends.
• Reviews claim data for process improvements.
• Communicates effectively and professionally with internal and external partners.
• Consistently meets or exceeds individual performance expectations.
• Identifies and reports potential quality or fraud issues to per established procedures.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Benefits & Perks

• Medical, Dental and Vision Coverage
• Generous paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time
• Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $54,913.37- $57,964.10 depending on experience*