Claims Adjudication Executive

3 weeks ago

Bengaluru, India Medical Billing Wholesalers Full time

Boost your career prospects as a Claims Adjudication Executive with Medical Billing Wholesalers, one of the fastest-growing offshore medical billing companies. At MBW, normal is truly boring and provide you with exciting opportunities to learn and work with your customer to grow your career. Our remuneration is in line with industry standards along with attractive benefits.

Adjudicate both institutional and professional claims in an efficient, cost-effective, and timely manner.

Responsible for determining financial responsibility between groups, health plans, and contracted hospitals for accurate processing of claims.

Interprets contract coverage for medical HMO claims. Review and interpret provider contracts to properly adjudicate claims. Review and interpret the Division of Financial Responsibility (DOFR) for claims processing.

OPPS APC, Ambulatory Surgery pricing, and RBRVS payment guidelines.

Understands eligibility, enrollment, and authorization process.

Knowledge of prompt payment guidelines for clean and unclean claims.

Process claims efficiently and maintains the acceptable quality of at least 95% on reviewed claims.

Meets daily production standards set for the department.

Prepares claims for medical review and signature review per processing guidelines.

Identify the correct received date on claims, with knowledge of all time frames for meeting compliance for all lines of business.

Assist customer service as needed to assist in claims resolution on calls from providers.

Researches authorizations and properly selects appropriate authorization for services billed.

Coordinate with the claims clerks on issues related to the submission and forwarding of claims determined to be the financial responsibility of another organization.

Coordinate Benefits on claims for which member has other primary coverage.

Adhere to MBW’s information security guidelines

Be in the center of ethical behavior and never on the sidelines

Should have a minimum of 3 years of experience in Claims Adjudication of institutional and professional claims experience in a Managed Care/IPA Claims environment for Medi-Cal, Medicare, and commercial managed care claims.

Knowledge of the overall claim workflow as well as compliance guidelines.

Knowledge of CPT, HCPCS, ICD-10 codes and claims processing for HCFA-1500 and UB04 claims.

Strong knowledge of all types of medical claims processing.

Excellent Typing Skills

Good written & verbal communication

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