Claims Adjudicator Ii

Looking for a way to influence the health and healthcare of many?

If so, we’d love to hear from you! Our mission-driven organization is focused on the “Triple Aim” - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans.

UNITE HERE HEALTH serves 190,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

Key Attributes:

• Integrity – Must be trustworthy and principled when faced with complex situations
• Ability to build positive work relationships – Mutual trust and respect will be essential to the collaborative relationships required
• Communication – Ability to generate concise, compelling, objective and data-driven reports
• Teamwork – Working well with others is required in the Fund’s collaborative environment
• Diversity – Must be capable of working in a culturally diverse environment
• Continuous Learning – Must be open to learning and skill development. As the Fund’s needs evolve, must be proactive about developing new areas of expertise
• Lives our values – Must be a role model for the Fund’s BETTER Culture and Mission (Better, Engage, Teamwork, Trust, Empower, Respect)

UNITE HERE HEALTHis seeking a Claims Adjudicator II to receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as provider and member driven inquiries.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Screens claims for completeness of necessary information
• Verifies participant/dependent eligibility
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
• Codes basic information and selects codes to determine payment liability amount
• Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
• Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
• Handles the end to end process of Medicare Secondary Payer (MSP) files
• Processes Personal Injury Protection (PIP) claims
• Requests overpayment refunds, maintains corresponding files and performs follow-up actions
• Handles verbal and written inquiries received from internal and external customers
• Processes Short Term Disability claims
• Adjudicates claims according to established productivity and quality goals
• Set goals and achieve measurable results
• Contributes ideas to plans and achieving department goals
• Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth
• Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation

ESSENTIAL QUALIFICATIONS

Must be fully vaccinated for COVID-19

Years of Experience and Knowledge

• 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment, or 3 years in health care or insurance environment
• Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Working knowledge and experience in Subrogation and its related processes
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
• Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes

Education, Licenses, and Certifications

• High School Diploma or GED
• College degree preferred

Skills and Abilities

• Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook)
• Intermediate level Microsoft Excel skills
• Intermediate level system(s) skills in Javelina claims system or other similar system preferred
• Preferred fluency (speak and write) in Spanish
• Communication skills (verbal and written)
• Problem solving, multi-tasking and decision-making skills
• Customer service