Philadelphia, Pennsylvania
Medical Claims Reviewer (DRC) Job Opening in Philadelphia, Pennsylvania - Job Summary
Under close supervision, the DRC Reviewer performs a variety of activities to ensure accuracy and completeness of associated documents, medical documentation and claims processes for Decision Ready Claims (DRC). Utilizing the VA VBMS (Veteran Benefit Management System) and CAPRI systems, conduct medical documentation research. Enter required DRC exam information into the VA VBMS, review and develop information for processes and diagnosis based on training and knowledge of medical process and procedures performed. Reviews final documentation for accuracy and obtains finalization form medical professionals. Will determine the recommendation to send DRC to VBA.
Essential Duties and Responsibilities
Provide quality and complete reviews for all DRC claims
Responsible for the timeliness and quality of all DRC submissions ensuring claim submission is completed within the appropriate timeframe
Responsible for complete understanding of workflow of VA and proprietary software and systems including all claim touchpoints
Partner with VSO?s (Veteran Service Organization) to inform of quality or medical deficiencies noted that prevents a case from moving forward
Meet personal productivity and quality goals
Perform other duties and responsibilities as assigned
Competencies :
Working knowledge and understanding of medical terminology, anatomy and physiology
Working knowledge with case management software, electronic medical records (EMR) and medical databases
Ability to work independently and with a team at all levels of the organization
Excellent verbal and written communication skills
Proven ability to organize, plan, coordinate and multi-task
Able to work with a high sense of urgency and follow through while maintaining professional composure
Ability to investigate, fact find and provide evidence towards DRC case submission
Excellent computer skills
Proven analytical skills
Must possess the ability and flexibility to work early morning, evening, and/or weekend shifts
Education and/or Experience: ( includes certificate & licenses )
BA/BS degree preferably in a medical related field of study
Vocational training in a specific job function in a medical related area of study (e.g., LVN, LPN, EMT, MA, Military Medic, etc.) preferred
4 to 6 years of experience in healthcare, medical or insurance related industry
Must satisfactorily pass DRC Reviewer Training Program
Must be able to successfully pass National Agency Check with Inquiries (NACI) background investigation
This job description supersedes all prior job descriptions and is intended to describe the general content and essential requirements for the position listed above. It is not to be construed as an exhaustive statement of requirements, duties and responsibilities. Management reserves the right to add or change the duties of this position as required at any time.
QTC Management Inc. is a VEVRAA Federal contractor and an Equal Opportunity Employer. The company has an ongoing commitment to affirmative action and the creation of a workplace free of discrimination, harassment and retaliation. The company recruits, hires, trains, and promotes individuals in all job titles without regard to race, color, creed, religion, ancestry, national origin, age, sex, sexual orientation, people with disabilities protected under law, and protected veteran status.
Job Type: Contract
Required education:
Bachelor's
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