Claims Project Specialist

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Imperial Management Administrators Services

The Claims Project Specialist position will be responsible for researching claims related projects to identify root cause, trends, and solutions. The specialist will review a project request to identify scope, work with necessary departments to resolve any issues and process claims related to the project. Work closely with the manager to identify any problems and issues along with providing recommendations on how resolve future problems. Maintain quality and production standards, teamwork and comply with company/administrative policies and guidelines.

ESSENTIAL JOB FUNCTIONS:

1. Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e., co-payment, deductible, etc.

2. Compile special project data to present to leadership and providers/clients.

3. Review and process facility (UB-04) and professional claims (CMS-1500).

4. Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups and company policies and procedures.

5. Process Medicare member claims based on DMHC and DHS regulatory legislature.

6. Review services for appropriateness of charges and apply authorization guidelines during claims processing.

7. Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines.

8. Complete tasks assigned by management and attend meeting/conference call as necessary.
9. Ensures compliance with all applicable Federal, State and/or County laws and regulations related to our documented guidelines and processes.
EDUCATION/EXPERIENCE:

· Associate degree (A A.) or equivalent from two-year college or technical school; some college courses, or six months to one-year related experience and/or training; or equivalent combination of education and experience.

· Must have at least 3 years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and some exposure to the responsibilities from a level III.

· Candidates with multi-product line claims adjustment experience, preferred.

SKILLS/KNOWLEDGE/ABILITY:

· Must be familiar with ICD-9, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices.

· Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and Ez-Cap Claims adjudication software, preferred.

To apply for this job please visit forms.office.com.