Evolutions Healthcare Systems Looking for Claims Processor Customer Service Analyst at New Port Richey, FL Full Time

REPORTS TO: Chief Operating Officer

DEPARTMENT: Claims/Customer Service FLSA STATUS: NON-EXEMPT

MISSION: “TO PROVIDE INNOVATIVE MANAGED CARE SOLUTIONS FOR THE BENEFIT OF EVERYONE”

PURPOSE

The ideal candidate will be responsible for processing medical and workers compensation claims, based on the preferred

provider’s contractual language while applying industry standards and practices and performing standard customer

service functions. The successful candidate must be able to interpret plan contract language and apply appropriate

contractual provisions with high quality while meeting production standards as defined by management

ESSENTIAL FUNCTIONS:
 Process complex claims for physician, hospital, and specialty areas with high degree of accuracy and productivity.

 Process adjustments, according to company policies and procedures.

 Respond timely to written appeals.

 Effective verbal and in written communication skills and provider related issues.

 Answer incoming calls from members, clients, and providers.

 Overtime, as required.

 Attend meetings.

 Other duties may be assigned by Management.

MANAGEMENT/SUPERVISORY RESPONSIBILITIES

N/A

QUALIFICATIONS, KNOWLEDGE & SKILL

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The

requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions.

 Minimum Requirements:
o Claims Processing

o Customer Service

 Resolving and responding to claims and repricing appeals

Excellent understanding of

o UB04 billing practices and codes including but not limited to Revenue, HCPCS, and MSDRG Codes

o HCFA 1500 billing practices and codes including but not limited to CPT and HCPCS Codes

o Medicare Modifier Rules

 Knowledge of medical terminology and coding rules.

 Computer proficiency and technical aptitude with the ability to utilize MS Office products.

 Highly organized and detail oriented.

 Able to work and adjust priorities in a fast-paced environment.

 Must be willing to accept responsibility and to show good judgment, initiative, honesty, integrity and

resourcefulness.

EDUCATION

 High School Diploma or equivalent. Some college preferred.

 Minimum 3 years of experience Medical claims examining/processing

 Minimum 3 years of resolving appeals.

LANGUAGE SKILLS

Fluency in English spoken and written

MATHEMATICAL SKILLS

Basic Computational, Statistics & Analytics

CERTIFICATE, LICENSES, REGISTRATIONS

N/A

EQUIPMENT USED

Personal Computer (including peripherals such as printers, plotters, etc.), and other Multi-Use Computers (Including

Peripherals Such As Printers, Plotters, Tape Drives Etc.), E-Mail, Calculator, Copier, Faxes, Telephone, Shredder

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an

employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to

enable individuals with disabilities to perform the essential functions.

Sight/Visual/Other Senses: Use sight to notice changing events in the work environment; use hearing to identify and

understand the speech of people; use hearing to notice changing events in the work environment.

WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee

encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable

individuals with disabilities to perform the essential functions.

Control your work pace or schedule of activities within defined perimeters; makes a significant contribution to the

organization; works with others on common tasks or projects; perform the same mental activities over and over;

perform the same physical activities over and over. Stress tolerance and flexibility with schedule. Responsibilities

sometimes require working evenings and weekends, sometimes with little advance notice.

Evolutions Healthcare Systems is a privately owned Provider Network Development and Management Company, based

in New Port Richey, Florida for almost 30 years. It is a boutique organization specializing in relationship management

(aka Customized Network Solutions) for self-funded plans, Hospital Systems, Employer Groups, and TPA’s nationwide for

Group Health, Workers Compensation (WC), and Medical Auto.

We are seeking individuals who enjoy working independently within a team environment and want to be challenged.

We offer industry competitive benefits in a relaxed work environment.

Interested parties may send their current resume and salary requirements to: [email protected]

Mission: “To Provide Innovative Managed Care Solutions for the Benefit of Everyone”