Claims Adjuster

Position Purpose

This position shall analyze the Reconsiderations submitted by providers and/or members to determine appropriate action within Department policy and procedures. This position is responsible for the accurate and timely processing of all medical and dental claims within the Departmental standards and procedures relative to HMO, PPO, TPA and Dental products.

Nature and Scope

This position is responsible for:

• Reviewing all member and provider Reconsiderations submitted by Customer Service to ensure disposition and appropriate follow-up action.  

• Making independent decisions as to what action should take place, ensuring State and Federal regulations are met and provider contract provisions and member benefit plans are adhered to--unless otherwise directed by appropriate health plan management.  

• Working with Reimbursement Services to consult with interdepartmental staff in determining the appropriate course of action to ensure all issues are resolved. 

• Processing all adjustment claims to include voids, refunds, and provider and member appeals.  

• Reviewing claims that are pended for authorization requirements.

• Ensuring claims are processed according to Health Plan, Departmental and State and Federal regulations/procedures.  

• Ensuring that appropriate member benefits are processed.  

• Researching claims as needed in order to adjudicate timely and accurately.  

• Completing projects as assigned by the Claims Manager or other health plan management.  

• Participating in quality improvement and change management procedures and processes.

The Incumbent must have the ability and desire to work in an environment with quality and production goals. 

The Incumbent must comply with all Company HIPAA policies and procedures.

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications
Requirements - Required and/or Preferred

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Two-year degree from an accredited college or university or equivalent experience in a healthcare related field is required.

Experience:

Three years experience in claims or medical billing, managed care systems, including HMO, PPO, Dental, TPA, and Medicare products which included processing of coordination of benefits and subrogation. Knowledge of CPT, ICD9/10, HCPCS, ASA, ADA and DRG coding required. Experience with medical terminology is required. Experience with interpretation of health plan benefits, provider contract provisions and state and federal regulations is required.

License(s):

None

Certification(s):

None

Computer / Typing:

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.