Scope of position: The Claims Adjuster is responsible for performing centralized appeal processing functions for AvMed physicians, facilities, and ancillary providers. Identify claims problems and propose solutions.

• Essential Job Functions:
• Reviews and makes administrative determination on claim reviews received from providers and other sources.
• Adjust claims resulting from reviews and administrative decisions.
• Interpret policy and procedures to properly adjudicate and review all types of claims. Conduct appropriate research and system inquiries to obtain claim–related information. Perform special projects related to claims review problems. Adjust claims as needed, based on appropriate information.
• Identify and communicate system, provider, and other adjudication problems to improve first time claim processing accuracy.
• Identify providers needing claims experience reviews.
• Understand and apply HIPAA compliance rules when releasing Protected Health Information.
• Interact with other departments to resolve member and provider issues.
• Complies with company policies and procedures, which includes dress code, punctuality as they relate to work time, lunch, and break periods.
• Performs additional duties and responsibilities as assigned by management.

You have:

• Associates required
• Bachelor's in business or related field preferred 
• 3-5 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits. Previous audit or system configuration experience preferred
• An equivalent combination of education and experience may be considered 

You May Also Have:

• Strong verbal and written communication skills
• Strong analytical and interpretative skills
• Excellent organizational skills
• Effective problem-solving skills and ability to handle simple and complex tasks
• Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing priorities.
• Medical Coding including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10) and Diagnosis-related Group (DRG) Codes
• HRP, MACESS, or Similar Software Systems
• Microsoft Office Suite (Word, Excel, Access)

• Certified Professional Coder (CPC) - Certification - American Academy of Professional Coders (AAPC)

• High School Grad or Equivalent

• Health Plan Claims Disbursmnts 3 years
• Customer Service 3 years
• Administrative 3 years

• Writing
• Typing Speed 30 WPM
• Technology/Computer
• Project Management
• Microsoft Word
• Microsoft Excel