· Personnel Home · MQ’s · Index · Examination Code: R ·
Nature of Work
Under general supervision, performs technical work at the
full-performance level, reviewing benefits payables which have
been identified as questionable benefits and to collect medical
evidence for appeals of denied medical procedures. Examines
requests, claims and invoices for medical treatments as required
by the West Virginia Public Employees Insurance Agency and
advises PEIA Clinical staff on medical and pharmacy appeals.
Performs related work as required.
Distinguishing Characteristics
This position is characterized by the review of requested medical
procedures and/or invoices that were denied. The employee
researches the claim, determines why the medical procedure or
invoice was denied, and resolves the issue within rules,
regulations, and guidelines established by the PEIA or researches
the medical literature to find evidence-based or peer-reviewed
documentation to support approval or denial of the requested
services.
Examples of Work
Reviews computer printouts which identify questionable medical
invoices by exception codes.
Reviews microfiche or hard copy files of claimant medical reports
to determine whether payment is appropriate.
Reviews medical documents, including but not limited to physician
notes, x-ray reports, surgery reports, hospital discharge
summaries and other materials and correspondence, to determine
whether the treatment, equipment, or services rendered is
appropriate per the Agency benefit.
Corrects errors made in the processing of medical benefit
payments via adjustment forms or correspondence.
Drafts letters to members and providers under their own signature
or the Medical Director's signature.
Communicates verbally with members and providers to request or
give information regarding payment of medical benefits.
Confers with the Medical Director and Pharmacy Director on the
evidence obtained and makes recommendations for future action, if
required.
Knowledge, Skills and Abilities
Knowledge of the West Virginia Public Employees Insurance Agency
laws, rules and procedures.
Knowledge of medical terminology and anatomy.
Knowledge of medical codes.
Knowledge of basic arithmetic.
Ability to interpret medical codes, medical documentation and
medical reports.
Ability to make decisions as to whether or not payment of medical
benefits is proper, based on WV Public Employees Insurance
Agency benefit, laws, rules and regulations.
Ability to use office automation software and internal medical
claim data systems.
Ability to communicate effectively with a wide variety of people,
both orally and in writing.
Ability to operate a variety of office equipment.
Minimum Qualifications
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Training:
Graduation from a standard high school or the
equivalent.
Experience:
Four years of full-time or equivalent part-time paid clerical
employment including at least two years auditing or processing
health insurance claims, in a health care setting using medical
code, or health insurance.
Substitution:
Course work from an accredited four-year college or university,
or related business school or vocational training may substitute
through an established formula for up to two years of the
required non-specific experience.
Established: 12/1/91
Title Change: 1/16/09
Revised: 1/16/09
Effective:
1/16/09