The Claims Adjudicator employee will be primarily responsible for adjudicating medical/dental/vision/hearing/prescription claims. This person will need to be able to able to understand and apply benefits as described by the Summary Plan Description and have familiarity with CPT, HCPCS, ADA and ICD coding. Responsible for the accurate and timely processing of paper and electronic claims for benefits in accordance with policy provisions. Experience in medical claims processing is preferred.

Work Tasks

• Process medical, dental, vision, hearing and prescription claims
• Coordinate benefits with Medicare claims
• Evaluate claim material to determine eligibility
• Apply appropriate benefit codes to ensure policy benefits are paid accurately
• Request additional information when required
• Apply appropriate denial codes if no benefits are payable
• Interface with outside vendors or other departments within the organization

• Knowledge & understanding of ICD-10, CPT, HCPCS & ADA codes
• Understanding of HIPPA guidelines
• Basic knowledge of medical procedures and terminology
• Familiar with Microsoft Office, Outlook, Word & Excel
• Ability to decipher generic vs. brand name prescription drugs

REQUIRED SKILLS & ABILITIES;

• Experience with health insurance claims
• Strong attention to detail
• Problem solving
• Professional phone etiquette and customer service
• Effective team player
• Basic computer skills
• Outstanding oral and written communication skills
• Strong data entry skills