CLAIMS ADJUSTER

Position: Claims Adjuster

Job Purpose:

Under limited supervision of the Supervisor this position will apply techniques to process routine and complex claims, analyze expenditures and make recommendations for third-party liability claims.

Job Duties:

• Reviews plan documents and procedures to apply plan provisions, limitations and exclusions when making benefit determinations.
• Provides customer service to all members, providers and/or Local Union personnel and/or other persons, as necessary, concerning claims processing.
• Performs computations and authorizes payment to a maximum of $25,000.00.
• Communicates professionally in written or oral format as necessary to request and receive data on incomplete claims and requests investigation when necessary, according to procedures.
• Applies knowledge and procedure to third-party liability claim claims.
• Exercises professional judgment on daily tasks and seeks approval from supervisor when current or for new or unfamiliar tasks.
• Maintain a 10 business-day turnaround time on assigned claim responsibilities.
• Maintain and update a pending file with follow-ups on correspondence as required.
• Ability to meet production and quality goals on a consistent basis as outlined by department management.
• Corresponds with providers, insurance companies and/or external vendors on various matters relating to claims.
• Routes claims requiring review to the assigned Claim Adjuster Senior II.
• Demonstrates knowledge of assigned duties as well as the legacy and recently migrated claims processing system.
• Performs other related duties as assigned.

Minimum Qualifications:

• 6 months as a Claims Examiner and 6- months as a Claims Examiner within WPAS or 2 years of comparable outside claims processing experience.
• Working knowledge of basic office equipment.
• Proven track record of positive interpersonal communications with internal and external clients and vendors.
• Demonstrated ability to keep calm and positive within all communications.
• Proven ability to accurately and timely complete assigned tasks.
• Utilize computer, phone systems and reference materials to be able to effectively perform the essential functions of the position.
• Previous experience utilizing Microsoft office software
• High school diploma or G.E.D

Preferred Qualifications:

• Previous experience processing claims within a TPA environment
• 2 years of college experience in a related field- do not have to have an associate degree

Physical/Mental Requirements:

• The physical and mental demands described here are representative of those that must be met by employees to successfully perform the essential functions of this job.
• While performing the duties of this job, employees are regularly required to use written and oral communication skills; read and interpret data, information and documents; analyze and solve non-routine and complex office administrative problems; use math and mathematical reasoning; observe and interpret situations; learn and apply new information or skills; perform highly detailed work on multiple, concurrent tasks; work under intensive deadlines with frequent interruptions.

Work Environment:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this class. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Employees work under typical office conditions.
• WPAS is an equal opportunity employer. We celebrate diversity and strive to continually create the most inclusive work environment for all our employees.

For additional information please contact: SanJoseRecruitment@WPAS-inc.com