Description
JOB SUMMARY
OCONUS will be working with claims outside of the continental US and will work with different currencies
This job is responsible for screening, reviewing, evaluating online entry, correcting errors and / or performing quality control review and final adjudication of paper / electronic claims.
Determines whether to return, deny or pay claims following organizational policies and procedures. Reviews processed claims and inquiries to determine corrective action including adjusting claims as necessary and takes the corrective action steps using enrollment, benefit and historical claim processing information;
may coordinate benefits and interact with customers. Responsible for the timely and accurate completion of claims adjustments which could be a result of internal / external audits, member / provider phone calls, other insurance information received, appeals, and system changes, etc.
provides technical assistance in researching and resolving inquiries.
ESSENTIAL RESPONSIBILITIES
- Receives and processes claims to include entering / verifying claims data; determines if claim information is complete and correct.
- Resolves claim edits, reviews history records and determines benefit eligibility for service. Reviews payment levels to arrive at final payment determination.
- Elevates issues to next level of supervision as appropriate and ensures a professional line of communication is maintained with internal and external customers.
- Meets all production and quality standards, ensuring timeliness and accuracy of all work given by support staff / management.
Maintains accurate records, including timekeeping records and attends all required training classes.
Other duties as assigned or requested.
EDUCATION
Required
High School Diploma / GED
Substitutions
None
Preferred
None
EXPERIENCE
Required
1 year of related experience
Preferred
- 1 year of claims processing experience
- Inquiry resolution system, OCWA, Oscar, Outlook experience
LICENSES or CERTIFICATIONS
Required
None
Preferred
None
SKILLS
- Strong verbal and written communication skills.
- Ability to take direction and to navigate through multiple systems simultaneously.
- Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
- Ability to use mathematics to adjudicate claims.
- Ability to solve problems within pre-defined methods and guidelines.
- Knowledge of operating systems specific to claim processing.
- Ability to review claims and analyze critical data.
- Reading benefits, investigating edits and making benefit determinations as required in adjusting and adjudicating most types of claims.
- Researches and finalizes claims, adjustments, inquiries and reports as required.
Language (Other than English) :
None
Travel Requirement : 0% - 25%
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Never
Travel regularly from the office to various work sites or from site-to-site
Never
Works primarily out-of-the office selling products / services (sales employees)
Never
Physical work site required
Lifting : up to 10 pounds
Constantly
Lifting : 10 to 25 pounds
Occasionally
Lifting : 25 to 50 pounds
Never
Pay Range Minimum : $16.50
$16.50
Pay Range Maximum : $22.20
$22.20
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation / gender identity or any other category protected by applicable federal, state or local law.
Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation / gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities / Women / Protected Veterans / Disabled / Sexual Orientation / Gender Identity ()
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please contact HR Services Online at
Claims Processor
Reviews processed claims and inquiries to determine corrective action including adjusting claims as necessary and takes the corrective action steps using enrollment, benefit and historical claim processing information; may coordinate benefits and interact with customers. Receives and processes claim...
Claims Processor II
Claims must be processed with a high level of detailed quality and in accordance with claims payment policy and by the terms of our customer/provider contractual agreements. Resolves claims edits and suspended claims. Manually prices claims with various tools and processes to pay the claims. Respons...
Property Subrogation Claims Adjuster (Primarily Home)
Assess and investigate claims for subrogation potential, including recognizing claims and making referrals to subrogation within stated guidelines. At American Family Insurance Claims Services (AFICS, Inc. You will primarily work from home and will report to the Property Subrogation Claims Manager. ...
Claims Settlement Specialist
The Claims Settlement Specialist supports claim settlement with providers through post payment negotiation. The Claims Settlement Specialist will be responsible for handling provider telephone calls regarding the payment amount paid to a provider by a payor based on Zelis data points. During this ca...
Legal Administrative Assistant
This Legal Administrative Assistant (LAA) position is a member of a 5-person multi-practice LAA team. Legal Administrative Support (75%). Maintains chronological files and administrative files for assigned attorneys. General and Administrative (5%). ...
Claims Analyst
In the role of Claims Analyst you will be responsible for handling assigned claims from initial assignment to closure, as well as provide assistance in various administrative functions associated with the Excess Workers' Compensation (WC) Line of Business. Our Claims department oversees both high-ex...
Data Entry Clerk
Performs data entry processes into a database. Under supervision, processes data entry transactions and performs other clerical duties as requested. Ensure complete and accurate data entries into system. Microsoft Office Suite and Database Systems. ...
Administrative Assistant
Sales Administrator opening at our St.The Sales Administrator’s mission will be to work closely with our sales team to help them move their prospects through the sales process.This position requires great attention to detail and an extremely detail oriented individual.Strong self-starter who p...
Administrative Assistant
We have an opening for a full-time Administrative Assistant position with duties including scheduling meetings and phone conferences with clients for multiple consultants, scheduling consultant travel, and word processing. Reports to Lead Administrative Assistant. Other administrative project ...
Customer Service Representative Fueler/Washer
Ready to accelerate your career while helping our customers move forward? As a Customer Service Representative Fueler/Washer at Penske, you’ll do exactly that. Why join Penske as a Customer Service Representative, you ask? It’s simple. Excellent customer service and communication skills. You will be...