Job Summary
This job includes claim processing and adjudication, with claims research where applicable. Incumbents must meet and/or exceed qualitative and quantitative production standards. Claims processing may range in level of complexity.

Essential Functions

• The essential functions listed represent the major duties of this role, additional duties may be assigned.
• Day-to-day processing of claims for accounts:
  
  - responsible for processing of claims (medical, dental, vision, and mental health claims)
  
  - claims processing and adjudication
  
  - claims research where applicable.
  
  - Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
  
  
  
  Incumbents are expected to meet and/or exceed qualitative and quantitative production standards.
  
  (80%)
• Investigation and overpayment administration:
  
  - Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
  
  - Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records.
  
  - Utilize systems to track complaints and resolutions. (10%)
• Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. (10%)

Required Work Experience
3+ years related work experience. Experience Details: Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry

Required Management Experience
No supervisory/management experience required

Required Education
High school diploma or GED

Additional Required Qualifications
Knowledge of CPT and ICD-9 coding required.
Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required.
Must possess proven judgment, decision-making skills and the ability to analyze.
Must learn quickly as well as be able to multi-task.
Must be motivated and possess a sound work ethic.
Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
Concise written and verbal communication skills required, including the ability to handle conflict.
Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding
Review of multiple surgical procedures and establishment of reasonable and customary fees.

Additional Preferred Qualifications
- some college courses in related field a plus. - Other experience in processing all types of medical claims helpful. - Data entry and 10-key by touch/sight required.

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.