Job ID: J121641
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Apr 23, 2018
This job is responsible for assisting in the processing and investigation of non-complex health care claims to determine the legitimacy of claim charges. The incumbent will also conduct or assist with provider and subscriber investigations to verify the validity of services and charges; will monitor internal referrals from sources such as claims, customer service, Medicare C&D Compliance, and Fraud Hotlines; will alert FIPR analysts of the need for further investigation; will perform claims system extracts and create reports, graphs and charts to support case documentation; will prepare necessary correspondence to set and monitor provider and member claim system flags; will work with external vendors to recover confirmed over payments; will participate in various internal committees as assigned; will update departmental tracking logs such as consultant listings and certified mail; and will input and maintain current case information in applicable case management tracking systems (FICO and FIMS). Please note that the essential responsibilities listed below depend on the level of the position.
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Unusual Working Conditions
This position is responsible for clerical research, lower end audit procedures, and other support functions required within the department to maintain an efficient and timely flow of documents and testing necessary to assist co-workers and management in the performance of their responsibilities.
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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