Job Description

The Encounters Specialist ensures that 100% of all encounters submitted to AHCCCS are accepted, processed and proper reimbursement is sent back to the health plan. This position also documents and reports inappropriate adjudication trends to facilitate additional staff training, examines AHCCCS pend and denial reports for processing inaccuracies, and reviews and works the TI portal to resolve any encounter validation issues.

Review and reconcile the AHCCCS pend correction and denial reports:
* Identify and correct errors
* Report trends to claims supervisor
* Ensure time frame for correction of pended encounters is met and report unresolved issues
* Communicate professionally with AHCCCS staff

Conduct claims specific research to resolve outstanding encounter pends:
* Research claim issues to identify root cause and determine corrective action to resolve issue
* Communicate findings to supervisor and/or trainer
* Maintain documentation of issues found/resolved as a result of the research performed

 
Perform claims adjustments and/or recoupments on incorrectly adjudicated claims:
* Perform the adjustment of claims, including pended encounters, denied encounters, claims stuck in the TI portal and any other adjustment that is necessary
* Accept claims in PMMIS that require override
* Reconcile withdrawn pended encounters
* Communicate with AHCCCS encounter staff regarding encounters that should be overridden

 
Support claims department by completing various job related tasks:
* Assist in identification of payment issues for resolution
* Examine and evaluate AHCCCS edits to determine compatibility to HCA’s MIS system
* Document and identify areas that require additional claim processor support

 

Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled


 



Qualifications

Qualifications:

High School Diploma or GED

At least one (1) year claim processing experience in HCFA 1500 and UB92s

At least one (1) year customer service experience in a managed care payer environment

Knowledge of medical terminology, CPT, HCPCS, and ICD-9, claims billing to include 1500s and UB92s, continuation plans

Application Instructions

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