• Assist the business teams with reviewing claims to ensure regulatory requirements are appropriately applied.• Assist with claims projects that may be initiated through provider inquiries, complaints, legal requests, or identified internally by Molina Healthcare.• Identify the root cause of processing errors through research and analysis, coordinate and engage with other departments, develop and track remediation plans, and monitor claims reprocessing through resolution.• Present… Show more • Assist the business teams with reviewing claims to ensure regulatory requirements are appropriately applied.• Assist with claims projects that may be initiated through provider inquiries, complaints, legal requests, or identified internally by Molina Healthcare.• Identify the root cause of processing errors through research and analysis, coordinate and engage with other departments, develop and track remediation plans, and monitor claims reprocessing through resolution.• Present analysis of findings and results to leadership and respective operations teams. Responsible for ensuring the projects are completed accurately and within the assigned deadline.• Use analytical skills to conduct research and analysis for issues, requests, and inquiries of high priority claims projects.• Assist with reducing re-work by identifying and correcting claims processing issues.• Identify claims requiring reprocessing or re-adjudication in a timely manner to ensure compliance.• Recommend updates to Claims SOPs and job aids to increase the quality and efficiency of claims processing. Show less

• Processed appeals and claims for STAR, STARKids, CHIP, and CHIP Perinate plans.• Ensured appeals were processed according to claims processing guidelines and contracts.• Reviewed and processed pended claims within 5 days of initial review.• Reviewed, researched, and applied provider refunds in a timely manner.• Processed refunds/retractions identified by TCHP contracted vendors within the required 30 day turn around.• Tested claims for functionality, accuracy, benefit… Show more • Processed appeals and claims for STAR, STARKids, CHIP, and CHIP Perinate plans.• Ensured appeals were processed according to claims processing guidelines and contracts.• Reviewed and processed pended claims within 5 days of initial review.• Reviewed, researched, and applied provider refunds in a timely manner.• Processed refunds/retractions identified by TCHP contracted vendors within the required 30 day turn around.• Tested claims for functionality, accuracy, benefit payment, contract interpretation, and compliance with policy and procedures. Identified errors utilizing our testing environment to ensure a prompt resolution.• Identified trends related to appeals and claims processing.• Extensive knowledge of ICD-10 diagnosis codes, CPT codes, coordination of benefits, HIPPA regulations, and medical terminology.• Continuously met the required daily production and monthly quality. Show less

• Position involves processing medical, dental, and vision claims for multiple Medicare Advantra replacement plans, processing high dollar claims, identifying and reporting possible claim overpayments, underpayments, and any other irregularities, making necessary outbound calls to obtain required information for initial claim reconsiderations, performing claim re-work calculations, verifying eligibility, and ensuring all compliance requirements were satisfied and all payments were made in… Show more • Position involves processing medical, dental, and vision claims for multiple Medicare Advantra replacement plans, processing high dollar claims, identifying and reporting possible claim overpayments, underpayments, and any other irregularities, making necessary outbound calls to obtain required information for initial claim reconsiderations, performing claim re-work calculations, verifying eligibility, and ensuring all compliance requirements were satisfied and all payments were made in accordance with company policy and procedures• Extensive knowledge of ICD-9, ICD-10, CPT codes, HCFA, UB-92, and UB-40 medical claim forms, coordination of benefits, HIPPA regulations, Medicare, Medicaid, and medical terminology. Show less

• Position involved processing medical, dental, and vision claims for multiple Medicare Advantra replacement plans, processing high dollar claims, identifying and reporting possible claim overpayments, underpayments, and any other irregularities, making necessary outbound calls to obtain required information for initial claim work or reconsideration, performing claim re-work calculations, and ensuring all compliance requirements were satisfied and all payments were made in accordance with… Show more • Position involved processing medical, dental, and vision claims for multiple Medicare Advantra replacement plans, processing high dollar claims, identifying and reporting possible claim overpayments, underpayments, and any other irregularities, making necessary outbound calls to obtain required information for initial claim work or reconsideration, performing claim re-work calculations, and ensuring all compliance requirements were satisfied and all payments were made in accordance with company policy and procedures, and trained to support call center activity as required, including general member and/or provider inquiries• Extensive knowledge of ICD-9, CPT codes, HCFA, UB-92, and UB-40 medical claim forms, coordination of benefits, HIPPA regulations, Medicare, Medicaid, and medical terminology. Show less

• Position involved processing hospital claims and coordinating them with Medicare benefits• Extensive knowledge of ICD-9 and CPT codes, HCFA, UB-92, and UB-40 medical claim forms, coordination of benefits, HIPPA regulations, Medicare, Medicaid, and medical terminology.

• Position involved processing medical, dental, prescription, and vision claims for commercial plans, processing high dollar claims, performing claim re-work calculations, and trained to support call center activity as required, including general member and/or provider inquiries• Extensive knowledge of ICD-9 and CPT codes, HCFA, UB-92, and UB-40 medical claim forms, coordination of benefits, HIPPA regulations, Medicare, Medicaid, and medical terminology.

• Position involved processing medical, dental, prescription, and vision claims for commercial plans, processing high dollar claims, performing claim re-work calculations, and trained to support call center activity as required, including general member and/or provider inquiries• Extensive knowledge of ICD-9 and CPT codes, HCFA, UB-92, and UB-40 medical claim forms, coordination of benefits, HIPPA regulations, Medicare, Medicaid, and medical terminology.