Healthcare Claims and Billing Representative

Job Description

REQUIREMENTS

• High school diploma required; Associates Degree or higher preferred
• Minimum 2 years Health Plan Operations experience including; Customer Service, Enrollment, and or Claims processing
• Working knowledge of MSOffice (Word, Excel, Outlook)

RESPONSIBILITIES

• Process queue items, inter-departmental and customer requests timely and accurately
• Review incomplete and pending enrollment applications and disenrollment forms for correction and submission to Centers for Medicare & Medicaid Services (CMS)
• Review and complete Late Enrollment Penalty (LEP) Attestations
• Review and complete Other Health Insurance (OHI) verification and error correction
• Review and create retro processing packets to be submitted to the CMS Retro Processing Contractor (RPC)

• Researching and correcting errors, discrepancies, and rejected transactions received from:
• CMS on the Daily Transaction Reply Report (DTRR)
• CMS Daily and Monthly Reconciliation queues
• Daily and Monthly Pharmacy Benefit Manager (PBM)
• Monthly MMR, PWR, LIS History and LEP Reconciliation
• Daily OHI/COB Rejections
• Monthly review and preparation of the CMS Enrollment Data Validation file and submissions

• Working understanding of Centers for Medicare & Medicaid Services (CMS) guidance
• Conform with and abide by all regulations, policies, work procedures and instructions
• Meet CMS guidelines and client Service Level Agreement (SLA) requirements through the proper handling of transactions
• Perform outbound calls to customers or other entities as permitted to complete processing of enrollment, disenrollment and reconciliation transactions
• Make appropriate system corrections and escalate transactions that are unable to be corrected
• Prepare reports as requested by management
• Perform other duties and responsibilities as required

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