2 claims adjudicator jobs found

Customer Service Rep I Full-time Shift: 8:00 am to 8:00 pm  (Shift bidding process based on seniority) Grand Rapids, MI Assessment required -  Customer Service Rep   Analyzes, evaluates, resolves and primarily responds to low complexity level membership issues under various product lines. Primarily conducts low complexity internal and external research to determine and request the data needed to handle inquiries regarding membership.  Analyze and service various product lines in the area (i.e., Facility, Professional). Provide responses by telephone, check-off letters, and/or automated letters. Follow department/corporate reporting requirements (i.e., PCRS, ICS, Special Surveys and Manual counts).  Organize work to meet Nati45onal/Corporate/Department Production and Quality Standards.  Reroute misdirected inquiries.  Primarily evaluates membership issues/inquiries and price/adjudicates low complexity claims/inquiries.  Interact with others inside and outside the...

SUMMARY Medical Bill Review Specialist I Primarily responsible for analyzing bills for multi-state Workers Compensation medical claims to determine appropriateness of services billed. Responsible for analyzing simple billings by utilizing our Medical Bill Review (MBR) software to determine appropriateness of codes. Responsible for making bill review processing determinations according to rules, regulations, and/or third-party partners. Medical Bill Review Specialist II Primarily responsible for performing technical review of more complex medical bills, including modifiers, anesthesia, & psychiatric. Responsible for analyzing billings including outpatient hospital and multiple surgeries by utilizing our Medical Bill Review (MBR) software to determine appropriateness of codes and excessive charges. Also responsible for analyzing assigned medical bills to determine compliance with business rules, client specific requirements and multiple state rules, regulations and...