Claims Adjuster

Reporting to the Director of Claims/Insurance/Third Party Recovery, the Claims Adjudicator or Adjuster is responsible for the accurate and timely processing of claims. The position should meet quality and productivity standards, and make adjustments to previously processed claims.

Responsibilities:

• Evaluates and processes claims in accordance with company policies and procedures, as well as to productivity and quality standards.
• Interprets and processes routine and less complex claims including CMS 1500 and UB04.
• Reviews and analyzes data from system-generated reports for in-process claims in order to identify and resolve errors prior to final adjudication.
• Alerts the Director of Claims about aging issues as well as provider billing problems.
• Maintains current knowledge of UHS member benefits, policies and procedures, provider network development and contract issues, processing system issues, state regulations, and industry standards for claims adjudication.
• Consistently maintains production and quality standards based on quality control expectations.
• Make outbound calls or visits to union offices and facilities to re-assess members' current health plans and to identify gaps or barriers for further analysis and resolution to ensure the appropriateness of benefits.
• Assists claimants, providers, and clients with problems or questions regarding their claims and/or policies.
• Answers calls and inquiries from family and enrollees and assess claims to ensure the appropriateness of benefits.
• Act as a patient advocate, protecting privacy and confidentiality issues.
• Enters codes and verifies data for computer processing.
• Prepares and prints drafts for payment of claims, refund requests and verifies that payments have been made.
• Secures needed medical documentation required or requested by third party insurances
• Opens and processes mail daily.
• Compiles and prepares statistical data and reports.
• Consistently maintains production and quality standards based on quality control expectations.
• Assists physicians with completing various forms for patients, particularly for disability claims.
• Interprets for physicians and patients upon request.

Qualifications:

• High School graduate or higher
• Minimum of one year of claims and interpretation of contracts experience
• Previous work experience in managed care preferred but not required
• Working knowledge of healthcare industry, insurance claims, government programs related to care management is an advantage
• Working knowledge of MS Office applications
• Organized and detail-oriented
• Strong customer service orientation
• Knowledge of using Microsoft Word and Excel, as well as medical terminologies

Job Type: Full-time

Pay: From $18.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Experience:

• claims processing: 1 year (Required)
• data entry: 1 year (Preferred)
• medical billing: 1 year (Preferred)
• Healthcare: 1 year (Preferred)

Work Location: In person

Salary : $18