Responsibilities

Job Summary: This individual enters and adjudicates claims for all Health Plans products ensuring that all covered claims are paid in a timely basis. This individual also resolves questions regarding coverage of claims and benefits, functioning in the role of customer service representative for enrollees, other Health Plans Division Departments, providers and their office staff, and insurance companies. 

Qualifications

Job Duties/Responsibilities:

• Analyzes and correctly processes claims in accordance with plan benefits and provider contracts in order to consistently meet or exceed the financial and statistical accuracy rates as established in the Claims Department Performance Standards.
• Consistently meets or exceeds the claims adjudication quota as set forth in the Claims Department Performance Standards.
• Responsible for processing claims within the timeframe set forth by the Claims Department Performance Standards.

Requirements: 

• Associates degree or equivalent experience.
• Minimum 2 years’ experience in health care claims processing, preferably in a managed care environment, including customer service experience.
• Minimum 1 year experience in advanced computer systems.
• Knowledge of medical terminology necessary, CPT-4 procedure and ICD-9 (10) diagnostic coding knowledge.

• Excellent verbal and written communication skills; organizational skills; ability to interpret and apply established policy and procedure.

• Ability to plan, organize, and maintain priorities and schedules, as well as assure that deadlines are met.
• Ability to maintain confidentiality.
• Ability to perform data entry with speed and accuracy.