Claims Representative - Remote

Claims Representative – Remote – Proclaim

SUMMARY

The claims representative is responsible for manually reviewing and processing medical, supplemental, or dental claims. Claims are processed according to benefits, eligibility, and internal processes, policies, and procedures and may be completed, held for additional information/review, or denied. New claim representatives will be provided with a robust training program, which includes virtual classroom training, on-the-job learning/feedback, and gradually increasing claims per hour/quality requirements over several months. After completion of training, claim representatives must meet specific accuracy/quality, volume/claims per hour, and on production performance metrics.

RESPONSIBILITIES

·        Independently research and navigate various documents and databases to accurately process claims, ensuring compliance and adherence to established guidelines.

·        Confirm the presence of necessary documents within submitted claims.

·        Validate the accuracy of medical codes provided in claim submissions.

·        Assess the eligibility status of claims based on established criteria.

·        Review and verify other insurance coverage information in submitted claim.

·        Evaluate authorizations provided in claim submissions for accuracy.

·        Analyze account benefit plans to ensure claims align with coverage and policies.

·        Identify discrepancies, errors, or missing information.

·        Utilize multiple computer applications simultaneously.

·        Maintain self-discipline, consistently uphold a strong work ethic, and complete work tasks/responsibilities while working without close supervision.

·        Meet or exceed quality and productivity goals.

·        Identify claim processing learning opportunities by working directly with supervisors, coaches, and trainers to learn efficient and effective processing techniques and workflows.

·        Utilize a variety of virtual tools, including Outlook email, Cisco Webex, and similar applications, to effectively collaborate, communicate, and stay connected with colleagues and supervisors.

QUALIFICATIONS

·        High school diploma or equivalent

·        Ability to quickly learn a variety of computer applications to complete job functions,

·        Experience sending/receiving emails, scheduling calendar appointments/sending invitations, attaching files in Microsoft Outlook.

·        Knowledge of basic Microsoft Excel functions, such as filtering/sorting.

·        Experience in navigating multiple computer applications through the use of shortcut keys and other techniques.

·        Detail-oriented with experience in applying complex policy/procedure documents.

·        Strong organizational skills to maximize available work time. Ability to prioritize tasks to ensure job tasks are completed before deadlines.

·        Proven experience completing work with quality and productivity performance standards.

·        Experience working independently in a virtual environment preferred.

·        Experience with medical and insurance terminology in a professional setting preferred.

·        Knowledge of CPT/ICD-10 codes preferred.

·        Proven experience in health insurance claims processing or similar field preferred