PURPOSE OF THE JOB

Claims Processors adjudicate incoming claims in accordance with policies, procedures, and guidelines (as outlined by the company) regulatory requirements and contractual agreements. Processors are subject to production and quality standards to help ensure claims are processed correctly the first time.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• 1+ years

Required Education

• High School Diploma or GED

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• N/A

Preferred Education

• Associate's Degree in general field of study

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Adjudicate claims according to regulatory, contractual and health plan requirements

• Pre-screen accuracy of EDI submissions through review of data elements in claims system

• Verify claim is not duplicate of previously submitted claim

• Keep updated with processing manual and other educational/training materials

• Know and adjudicate claims according to COB provisions

• Identify and refer TPL issues to appropriate department

• Identify and refer medical review claims to appropriate department

• Identify and refer potential FWA claims to appropriate department

• Identify opportunities for provider education

• Identify opportunities for process improvement, including auto adjudication

• Perform all other duties as assigned

• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

• Claims processing, including UB, 1500 and dental

• Medical terminology

• CPT/HCPC and ICD10 coding

• Medicaid and Medicare

• Experience with multi-tasking and prioritzing

• Type 30 to 35 words per minute with 5% error rate or less

• Intermediate PC proficiency

• Strong oral and written communication skills

• Proficient spelling, punctuation and grammar skills

Required Professional Competencies

• Maintain confidentiality and privacy

• Compose and dictate a variety of business correspondence

• Interpret and translate policies, procedures, programs and guidelines

• Capable of investigative and analytical research

• Navigate, gather, input and maintain data records in multiple system applications

• Follow and accept instruction and direction

• Establish and maintain working relationships in a collaborative team environment

Required Leadership Experience and Competencies

• N/A

PREFERRED COMPETENCIES

Preferred Job Skills

• Type >35 words per minute with 5% error rate or less

• Intermediate knowledge of CPT, HCPCS and ICD9 claim coding

• Intermediate understanding of dental and medical terminology

• Intermediate comprehension of anatomy and medical practices

• Bilingual (Spanish/English) skill in written communication

Preferred Professional Competencies

• Knowledge of a wide range of subjects pertaining to the organization's service and operations

Preferred Leadership Experience and Competencies

• N/A