Shaunda S.

Processing and auditing all professional and facility medical claims, and prepayment audits. Call Health Plans to obtain member's coverage/eligibility, and or benefits. Troubleshoot claims that have been identified as needing additional work in the areas of eligibility, referral /authorization and contracting or provider set-up. Train and assist other analyst with problem claims. Knowledge of the IDX and Macess systems. Determine is a patient's services are covered, verses non covered. Look up member's benefit plan, member's PCP. View a member's authorization's/referral's, to see is services have been denied or authorized. Work on contracted and non-contracted claims. Make decisions regarding authorization's/referral's from the Care Management/Utilization Management Team. Knowledge of Compliance relate to the processing of claims. 28-30 days for Commercial Claims, and 58-60 days for Senior Claims, (Medical Advantage). Ability to research and verify claims payment issues. Knowledge of Compliance claims that need to be released in a timely manner. Run Pivot report for all claims received on a daily basis. Run a completed report at the end of the day, for all claims that processed for that day, on a daily basis. Give copy of Error's to the Eligibility Department, Utilization Department, Benefit Department, on different issues that require updating, authorization's that need updated or a referral/benefits that are covered, that has been denied.