Health Insurance Claims Adjuster

Job Description

Job Description

Our client is seeking a Health Insurance Claims Examiner for a leading insurance company in RI, in a temporary to permanent hire position.

On-Site position

This role acts as the single point of contact for their assigned accounts for any claim related issue. They

are the liaison / advocate between the provider and internal departments. The Senior Claim Adjuster works directly

with practice managers, via phone, email and in-person meetings on a regular basis to resolve outstanding claim

issues. This role works with our Provider Contracting and Provider Relations departments to assist in managing the

operational aspects of the provider relationship, and will attend internal meetings to present their research and

findings on claims issues. This role serves as a claims subject matter expert (SME) and is responsible for incoming

inquiries regarding current claims and escalated issues. Collaborates in strategic planning for their assigned

accounts. Works collaboratively with business and operational units to ensure prompt resolution of open issues. You will investigate, analyze, and determine the extent of the organization's liability in various claims, and process for payment.

Responsibilities, include, but not limited to :

• Serves as the SME and Lead on functional deliverables ensuring optimal efficiency in all areas of responsibility
• Tracks and maintains all known issues, including the operational provider issue logs, and implements work plans to improve claims accuracy and systemic issues that decrease efficiency or provider satisfaction.
• Conducts extensive research on complex payment inaccuracies and documents root cause analysis and mitigation
• Receives and responds timely to correspondence on escalated issues
• Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system
• Responsible for the review and processing of claims according to plan benefits and contractual terms.
• Request appropriate adjustment via AWD to the Claims BPO
• Attends ad-hoc and regularly scheduled operational meetings with provider community within and outside of the organization

Qualifications :

Interested candidates must be able to pass a background check.

This is a 37.5- hour workweek, Monday through Friday.

For immediate consideration please submit your resume.