Claims Processor

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 ()

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