Claims Processor II

Job Summary:

Under direction supervision, this position is responsible for the adjudication of post service claims including all edits and financial calculations for payment to providers or members.

Essential Responsibilities:

• Accurate payment of claims according to KFHPW processing procedures, provider manual agreements, Premier provider fee schedules, MFSDB pricing guidelines and vendor pricing software utilizing all reference material and baseline resources including the Web. Must meet or exceed productivity and quality standards.
• Adhere to KFHPWs Medical Management strategies by reviewing suspended claims against referral history in the RMS system. Release claims when an authorized referral exists for billed service. Deny claims where no authorized referral exists for billed service. Meet or exceed processing standards for referral related suspended claims.
• Responsible for complex manual calculations based on provider contractual agreements.
• Identify system and procedure discrepancies to supervisor for appropriate corrections. Back up data verfication, manual onlining, and intake work as needed. Communicate with internal and external parties to obtain information required for complex claim adjudication and follow-up on pended claims. Responsible for applying independent judgment to complex cases within the guidelines set by management.
• Accurately apply benefit rules to claims adjudication and limit tracking.