Responsibilities
• Review and assess healthcare claims for accuracy and compliance with payer agreements, fee schedules, and coding standards.
• Reprice claims using established guidelines, fee structures, and reimbursement methodologies.
• Verify the correctness of medical procedures and services coding based on industry-standard coding systems (e.g., CPT, ICD-10).
• Identify and rectify coding errors or discrepancies.
• Ensure claims adhere to contract terms, including negotiated rates and payment schedules.
• Verify that claims are processed in accordance with the provider’s contract with the payer.
• Maintain detailed records of claims repricing activities, including adjustments, calculations, and communications with providers.
• Generate and maintain accurate documentation of repricing decisions and justifications.
Qualifications and Requirements
• Familiarity with the healthcare industry, particularly in roles involving the evaluation and processing of claims.
• Proficient understanding of medical billing and coding systems, including CPT (Current Procedural Terminology), ICD-10 (International Classification of Diseases, 10th Edition), and HCPCS (Healthcare Common Procedure Coding System).
• Knowledge of healthcare reimbursement methodologies, fee schedules, and contractual agreements.
• Strong analytical and problem-solving skills to review and evaluate healthcare claims accurately.
• Clear and coherent in both written and verbal communication skills to effectively interact with healthcare providers and internal teams.
• Proficiency in using claims repricing software and other relevant computer applications.
• Keen attention to detail is crucial for identifying and correcting coding errors, ensuring accurate claim repricing, and maintaining detailed records.
• Understanding and adherence to industry regulations and compliance standards related to healthcare claims processing.
