Medical Adjudicator

Sanford Barrows Group LLC
Published
June 4, 2021
Location
Atlanta, GA
Category
Job Type

Description

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

• Review claim to verify claim entered with correct information vs submitted physical bill

• Confirm policy eligibility, review against policy permanent exclusions, and/or general policy exclusions, as well as identify possible pre-existing conditions

• Review benefit letter and system notes to verify that proper notification/pre-certification was received for treatment, where payment of member responsibility was allocated in order to apply accordingly, and authorization rendered by procedures performed, to process accordingly

• Review that diagnosis and treatment are correlated

• Review claimants submitted and paid claim history to verify policy accumulators

• Analyze the medical records of simple cases and assign an ICD-9 and CPT where necessary on simple claims

• Submit complex cases to Medical Team to review medical records for approval of condition and rendered services.

• Detect overcharges and apply corresponding contractual discounts or UCR

• Enter brief notes to explain if any charges were denied

DESIRED MINIMUM QUALIFICATIONS:

• Computer savvy (i.e. Microsoft Office, Internet Resources, etc.)

• Detail oriented with exceptional organizational and communication skills

• Complete Fluency in English and Spanish

Education and Experience:

• Associates Degree or commensurate with experience

• Billing/Coding Certification preferred

• Minimum of 3 years experience in Health Insurance Industry

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