Description

Position Purpose: This position examines, enters and accurately adjudicates medical, dental, vision, HRA, FLEX, or STD claims based upon coverage, policy and procedural guidelines. May be assigned multiple clients with several lines of coverage.

Primary Responsibilities:

To perform this job successfully, the individual must be able to perform each essential duty satisfactorily (the requirements listed below are representative of the knowledge, skill and/or ability needed). Reliable, consistent and predictable performance of the following job duties is required:

1. Enters paper claims into a proprietary claim adjudication system.
2. Adjudicates both paper and electronic claims with 99% accuracy for payment dollars and claim coding following an extensive on-the-job training class.
3. Maintains strict first-in/first-out for claims adjudication.
4. Follows office procedures for follow-up on claims needing additional information by reviewing the Holding for Information Report for each assigned client on a monthly basis.
5. Adjudicates prescription claims not automatically adjudicated by the claim adjudication system.
6. Interprets COB and Medicare worksheets as needed on assigned clients.
7. Batches adjudicated claims according to client preference or schedule.
8. Reports to clients on a weekly basis the total of all claims processed for that client, requesting the funding or requesting that funding be transferred to Pro-Claim.
9. Communicates with brokers, agents and clients regarding high dollar cost claims and SPEC claimants.

Critical Required Skills:

1. Must be able to work well independently and in a team atmosphere.
2. Ability to maintain a departmental accuracy standard of 99%.
3. Detail oriented.
4. Ability to manage multiple priorities that change from day-to-day and week-to-week in a fast-paced environment.
5. Ability to understand system calculations in order to determine if claims are adjudicating accurately.
6. Ability to manually process claims in the claims adjudication system if necessary.
7. Must understand complicated benefit designs.
8. Ability to self-manage, prioritize and meet specific production deadlines.
9. Computer experience, including Word, Excel, and Outlook.
10. Accurate 10-key and/or data entry skills.

Key Challenges:

1. Time-specific deadlines for adjudicating claims including end-of-the-year crunch as renewals occur for each client.
2. Maintaining the highest degree of confidentially with all things related to our business.
3. Must become familiar with CPT, ADA HCPC and ICD-10 codes, making adjudication easier.
4. Working in a high-volume, information-intensive environment.
5. Effectively using claims adjudication system.

Qualifications

Experience: A High School Diploma or GED required. Medical terminology and medical claims experience with involvement in reviewing and analyzing claims is beneficial.

Position Constraints: Significant amounts of time spent in visual, mental, and seated and/or standing work. Working within a specific deadline-driven environment. Manual dexterity.