Claims Adjudicator
Dayton, OH 
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Job Description

Job Summary

The primary function of this position is to process medical claims to completion, ensuring proper payment in accordance with the benefit plan reference and guidelines.


Job Duties & Responsibilities

  • Interpreting coding and understanding medical terminology in relation to diagnosis and procedures
  • Analyzes and answers inquiries regarding payment, co-pay or deductible amounts, and/or reason for denial.
  • Requests all information from internal and outside sources to ascertain completeness and validity of claim including coordination of benefits information.
  • Adjudicates for allocation of deductibles, co-pays, co-insurance maximums and provider reimbursements.
  • Analyzes the claims to determine extent of liability and settles the claims with claimants in accordance with policy provisions.
  • Researches claims as needed, assuring that quality levels are achieved.
  • Provides internal customer service to function areas for claim resolution.
  • Understands various insurance plans to ensure proper processing.
  • Adjusts overpayments, underpayments, and other irregularities.
  • Documents phone calls in system and follows up on issues if needed.
  • Exceeds productivity and quality standards as they are determined by the business needs on a continuous basis.
  • Works closely with Supervisors and Team Leaders.
  • Adheres to departmental policies and procedures.
  • Follows all procedures to ensure timely accurate claims review, approvals/denials, and payment as required.
  • Maintains and promotes positive employee relations in the work environment.
  • Works in a safe manner and reports unsafe activity.
  • Maintains high levels of safety awareness, a sound safety process to ensure positive team behaviors, and achievement of safety objectives.
  • Ensures that the security and privacy policies, standards and guidelines are disseminated, understood and applied in order to protect the informational assets of both the company and their customers.
  • Acts in accordance with the organization's information security HR and corporate policies.
  • Protects assets from unauthorized access, disclosure, modification, destruction or interference.
  • Reports security events or potential events or other security risks to the organization.
  • Other tasks duties and responsibilities as assigned.

Experience

  • High School diploma or equivalent
  • 3 years experience in health care adjudication
  • Familiarity with claims processing manuals, medical terminology, and CPT
  • codes and basic processing procedures
  • Proficiency in the use of claims processing software
  • Ability to read, write and speak English
  • Prepare accurate and grammatically correct written reports

Physical Requirements

  • Physical demands with activity or condition requiring a considerable amount of time include sitting and typing/keyboarding using a computer (i.e., keyboard, mouse, and monitor) or adding machine.Physical demands may include walking, carrying, reaching, standing, and stooping.May require occasional lifting/lowering, pushing, or pulling up to 25 lbs. Repetitive motion is required

Exela is committed to creating a diverse environment and is proud to be an equality opportunity employer. Qualified applicants will considered for employment without regard to their race, color, creed, religion, national origin, ancestry, citizenship status, age, disability, gender/sex, marital status, sexual orientation, gender identity, gender expression, veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local laws.


 

Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
High School or Equivalent
Required Experience
3+ years
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