HFHP Claims Examiner II - HF Claims Administration

Position Summary:

To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by reviewing and making adjustments or corrections to processed claims through researching, investigating issues, making a determination and then communicating as required. Authorize the appropriate adjustments. Conducting data entry and re-work; analyzing and identifying trends as well as providing reports as necessary. responsible and accountable for the accurate and timely claims processing of all claim types. Claims must be processed with a high level of detailed quality and in accordance with claims payment policy and by the terms of our customer/provider contractual agreements.

Primary Accountabilities:

• Communicate identified issues with claims and claims processes to the Lead within the claims department.
• Actively participate and collaborate with entire department to continuously improve workflows and performance.
• Ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions and employing active listening techniques.
• Adapt to and positively influence change by accepting feedback and capitalizing upon opportunities to continuously improve.
• Provide accurate and professional service to Client representatives, adhering to department policies.
• Maintain confidentiality at all times.
• Assist backup for Team Lead in their absence
• Adjudicating and/or adjusting claims and/or active pends and/or disputes, while ensuring claims are handled appropriately; claim contains pertinent and correct information for processing; member is eligible for coverage on the date(s) of service; services have the required referral/authorizations; accurate final claims adjudication/adjustments by using on-line computer claims payment system, which includes research on previously processed claims when needed; identify billing patterns, processing errors and/or system issues that inhibit the final adjudication of claims.
• Complete necessary adjustments to claims and ensures the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/certificates)
• Responding to client inquiries by researching, understanding and documenting information for each interaction accurately and timely.

Minimum Qualifications:

• High school diploma with 6 to 12 months of vocation/post high school education or equivalent work experience
• Minimum of 2.5 years claims processing, claims customer service or related health care billing experience.
• Advanced knowledge of medical benefits, medical and dental terminology
• Advanced knowledge of claim adjudication and benefit plan application for indemnity plans, HMO plans, POS plans or Medicare
• Proficient in Microsoft Office including: Microsoft Word; Excel and Access
• Advanced knowledge of Medicare eligibility, coverage and payment provisions
• Advanced knowledge of commercial insurance provisions