Under direct supervision, organizes claim forms and adjudicates claim payments for facility and professional claims related to managed care global admissions and capitated contracts.
Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
1. Organizes and logs facility and professional claims received by the managed care claims operations office.
2. Monitors and maintains unbilled files.
3. Bundles charges, invoices payors, and adjudicates payments and makes referral decisions for facility and professional claims on the claims system. Adjusts claims to correct payment errors, i.e. provider refunds and overpayment notices. Monitors and resolves complex claim payment problems.
4. Documents and maintains standard operating procedures for claims processing for managed care contracts and global contracts and assists with documenting and improving claims work flow process.
5. Handles customer service communications received from providers and payors through telephone inquiries, FAX and letters and explains payment decisions. Handles claim appeals. Assists with claims system testing and verification of claims logic outcomes.
6. Assists with the accounts payable process for claims and distributes and monitors claims disbursements to facilities and professional groups. Posts payer receipts and prepares EOBs for payments to hospitals and physicians.
7. Assists with problems that arise related to claim payments and check disbursements.
8. Assists with UMMS and professional group aged trial balance (ATB) reconciliation.
9. Provides training to Medical Center claims team members, as necessary.
10. Attends meetings with employees of the managed care department, UMMS and UPI professional groups to provide information and to solve problems concerning claims processing procedures.
As a University of Maryland Medical System (UMMS) employee, you will enjoy a comprehensive benefits program designed with you and your dependents in mind. Subject to any eligibility waiting period, all of the benefits are available to regular full-time employees and most benefits are available to regular part-time employees who are regularly scheduled to work twenty (20) or more hours per week. Many benefits are provided at no cost to employees. For others, the cost is shared between UMMS and employees.
Knowledge of medical terminology and health care coding including ICD-9, CPT, DRG, etc. Knowledge of claims processing, managed care contract and coordination of benefits concepts.
Knowledge, Skills and Abilities