Responsible to:
A. Adjudicate Medicare and Senior Advantage claims
for payment based on ICD-9 pay rules.
B. Contact providers and hospitals as needed to
clarify bills and verify accuracy of procedure codes.
C. Verify member benefits and eligibility and
manage coordination of benefits with other plans.
D. Determine payments according to RVRVS fee
schedule, and adjust incorrectly paid bills.
E. Input ICD-9 codes, provider notes, member
information, explanations, tracking information.
F. Update vendor/provider information, and forward
bills to utilization review nurses.

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