Description:
- Reviews and adjudicates routine claims in accordance with claim processing guidelines.
- Ability to work independently.
- Ability to think logically and problem solve.
- Strong oral communication skills.
- Analyzes and approves routine claims that cannot be auto adjudicated.
- Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
- Routes and triages complex claims to Senior Claim Benefits Specialist.
- Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
- Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
- Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope.
- Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.
- Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims.
- Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
- Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
- Analyzes claims data and generates reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.
Requirements:
- Less than 1 year work experience
- Working knowledge of problem solving and decision making skills
- Experience in a production environment.
- Medical claim processing experience (preferred)
- Medical coding background (preferred)
- Experience with Excel, Word, Teams and Outlook (preferred)
Benefits:
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs including wellness screenings, tobacco cessation, weight management programs, confidential counseling and financial coaching.
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access