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This position is responsible for multiple operational functions across the Member Services department, including the intake and analysis of membership enrollment and certification.
• Data management across multiple data management systems (including claims processing system, case management systems, and databases)
• Handling PII and PHI in adherence with HIPAA and federal data privacy regulations
• Communication with multiple business teams internally (Claims, Certification, Enrollment, Outreach) and the public.
• Maintaining subject matter expertise in the federal regulations that define the parameters of the World Trade Center (WTC) Health Program, which define Program eligibilities
• Daily processing of diverse work products in a high volume environment, maintaining the highest standards of customer service.
• Managing in-bound and out-bound calls, working with the public, and
• Identifying issues quickly and escalating them through the management chain as needed.
Duties for the Healthcare Claims Processor include:
- Resolving pended healthcare claims, prior approval requests and responding to providers.
Analyzing claims to determine whether or not the claims should be approved or denied for payment.
- Reviewing and addressing provider inquiries regarding claim adjudication
- Meeting all required metrics for the position
- Applying knowledge of medical coding and various medical claims forms to the claims process.