claims adjudicator

Job Summary:

The primary function of this position is to process medical claims to completion, ensuring proper payment in accordance with the benefit plan reference and guidelines.

Job Duties & Responsibilities:

• Interpreting coding and understanding medical terminology in relation to diagnosis and procedures

• Analyzes and answers inquiries regarding payment, co-pay or deductible amounts, and/or reason for denial.

• Requests all information from internal and outside sources to ascertain completeness and validity of claim including coordination of benefits information.

• Adjudicates for allocation of deductibles, co-pays, co-insurance maximums, and provider reimbursements.

• Analyzes the claims to determine the extent of liability and settles the claims with claimants in accordance with policy provisions.

• Researches claims as needed, assuring that quality levels are achieved.

• Provides internal customer service to function areas for a claim resolution.

• Understands various insurance plans to ensure proper processing.

• Adjusts overpayments, underpayments, and other irregularities.

• Documents phone calls in the system and follows up on issues if needed.

• Exceeds productivity and quality standards as they are determined by the business needs on a continuous basis.

• Works closely with Supervisors and Team Leaders.

• Adheres to departmental policies and procedures.

• Follows all procedures to ensure timely accurate claims review, approvals/denials, and payment as required.

• Maintains and promotes positive employee relations in the work environment.

• Works in a safe manner and reports unsafe activity.

• Maintains high levels of safety awareness, a sound safety process to ensure positive team behaviors, and achievement of safety objectives.

• Ensures that the security and privacy policies, standards, and guidelines are disseminated, understood, and applied in order to protect the informational assets of both the company and its customers.

• Acts in accordance with the organization's information security HR and corporate policies.

• Protects assets from unauthorized access, disclosure, modification, destruction, or interference.

• Reports security events or potential events or other security risks to the organization.

• Other tasks duties and responsibilities as assigned.

Experience:

• High School diploma or equivalent

• 3 years experience in health care adjudication

• Familiarity with claims processing manuals, medical terminology, and CPT

• codes and basic processing procedures

• Proficiency in the use of claims processing software

• Ability to read, write and speak English

• Prepare accurate and grammatically correct written reports

Physical Requirements:

Physical demands with activity or condition requiring a considerable amount of time include sitting and typing/keyboarding using a computer (i.e., keyboard, mouse, and monitor) or adding a machine. Physical demands may include walking, carrying, reaching, standing, and stooping. May require occasional lifting/lowering, pushing, or pulling up to 25 lbs. Repetitive motion is required

Title: Claims Adjudicator

Days/Hours: Monday – Friday, 8:00 am – 5:00 pm with potential Saturday work and overtime