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Medicare Claims Processor
Peak Health. Analyze and process Medicare insurance claims in accordance with CMS guidelines .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Proficient in analyzing and processing Medicare insurance claims in compliance with CMS guidelines, with a strong focus on accuracy, quality control, and effective communication. Demonstrates expertise in claims adjudication, customer service, and maintaining patient confidentiality under HIPAA regulations.
Highest-signal resume keywords
Medicare Claims ProcessingCMS Guidelines ComplianceQuality ControlCustomer ServiceMedical Terminology
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationData Entry AccuracyError CorrectionBenefit Eligibility DeterminationMathematics for Claims AdjudicationMedical CodingProcedure and Diagnosis CodesClaims BillingQuality Standards AdherenceRecord Maintenance
Soft Skills
Effective CommunicationInterpersonal SkillsProblem SolvingAttention to DetailTime Management
Tools & Technologies
EPIC Software
Industry Keywords
Medicare InsuranceHealthcare ClaimsPHI ComplianceHIPAA RegulationsThird Party Payors
About the role
Key responsibilities & impact- Analyze and process Medicare insurance claims in accordance with CMS guidelines
- Determine whether to return, deny, or pay claims according to organizational policies and procedures
- Screen, review, evaluate online entry, correct errors, and perform quality control for final adjudication of paper/electronic claims
- Ensure accuracy of data entered and maintain records
- Analyze claims to determine insurance carrier liability
- Resolve claim edits, review history records, and determine benefit eligibility for services
- Review payment levels and arrive at final payment determinations
- Interpret contract benefits and adjudicate claims according to Medicare claims processing guidelines
- Meet production and quality standards and maintain work queues
- Communicate effectively with internal and external colleagues
- Escalate issues to the next level of supervision as appropriate
- Attend required training and demonstrate proficiency
- Read and interpret explanations of benefits (EOBs)
- Mentor less experienced staff as assigned
- Maintain patient/member confidentiality under PHI and HIPAA guidelines
- Report to the Medicare Claims Supervisor
Requirements
What you’ll need- Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience
- One (1) year of Medicare claims processing experience
- One (1) year of experience working with CMS/professional and UB/institutional claims
- One (1) year of customer service experience
- Bachelor’s degree in medical coding or related healthcare field, OR 4 (four) years of equivalent industry work experience (preferred)
- Three (3) years of Medicare claims processing experience (preferred)
- Three (3) plus years of medical or institutional claims processing and customer service experience (preferred)
- Experience in Medicare medical insurance and Medicare supplement preferred
- Familiarity navigating the EPIC software programs preferred
- Ability to sit for extended periods of time
- Comfortable working at times with limited social interaction
- Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records
- Ability to take direction and navigate through multiple systems simultaneously
- Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette
- Ability to solve problems with predefined methods and guidelines
- Ability to use mathematics to adjudicate claims
- Ability to understand medical insurance requirements for payment and basic knowledge of covered services
- Knowledge and understanding of medical terminology, third party payors and insurance preferred
- Attention to detail, organization, independent work, critical thinking, time management, and ability to perform multiple tasks simultaneously
- Working knowledge of Medicare medical insurance terminology, procedure and diagnosis codes, and HIPPA requirements
Benefits
Comp & perks- Full-time position
- 40 scheduled hours per week