Job Purpose

The Claims Processor is responsible for accurate and timely processing of medical claims pended for manual adjudication in assigned Workflow roles. The Claims Processor will accurately interpret benefit and policy provisions applicable to fully-insured plan members and review claims to determine coverage based on contract, provider status, and claims processing guidelines. The incumbent must meet quality and productivity standards.

Duties and Responsibilities

• Reviews and adjudicates claims up to specified dollar limits
• Processes claims within performance guidelines of the department, including quality and timeliness
• Works with and understands Company benefit plans
• Understands provider contracts
• Examines and interprets all relevant documents included with the claims
• Responds to claim-specific questions, as applicable
• Partners with leadership on any questionable claim activity
• Understands logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.).
• Determines accurate payment criteria for clearing pending claims based on defined Policy and Procedures
• Researches claim edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for entry-level claims
• Works high volume of repetitive claims
• Identify claims with inaccurate data or claims that require review by appropriate team members
• Contributes positively as a team player
• Completes special projects as assigned and supports other Claims Department team members in assigned projects
• Complies with all departmental and Company policies and procedures
• Other duties as may be assigned
• Regular and predictable attendance
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice

Qualifications

• High School Diploma or GED required
• Associates or Bachelor's Degree preferred
• A minimum of 1 year experience in claims processing required; previous experience in medical billing and coding required if no claims processing experience
• Knowledge of ICD-10, CPT4, DRG, HCPCS codes, medical terminology, EDI and HIPAA protocols preferred
• Certified Professional Coder (CPC) preferred
• Experience with Word and Excel

Competencies

• Ethics - Honest, accountable, maintains confidentiality
• Reliability - The extent to which the employee can be depended upon to be available for work, do it properly, and complete it on time. The degree to which the employee is reliable, trustworthy, and persistent.
• Sense of Urgency - Meets deadlines, establishes appropriate priority, gets the job done in a timely manner
• Organization skills - Information organized and accessible, maintains efficient work space, manages time well
• Computer skills - Skilled with computers, takes advantage of new technology, learns new tools quickly, uses technology to enhance job performance
• Communication skills - Possesses effective communication skills: oral, written, listening
• Productivity - Manages workload, works efficiently, meets goals and objectives
• Initiative - Takes action, seeks new opportunities, strives to see projects to completion
• Planning & Organizing - Displays ability to effectively plan, organize and implement applicable tasks or projects in relation to established goals and objectives
• Quality - Strives to eliminate errors, accurate work is a priority, seeks opportunities to improve product/services

Physical, Mental, Environmental & Working Conditions

Moderate amount of walking, sitting, and writing. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day events in the execution of job duties. Needs flexibility and adaptability to change. Candidate must be self-disciplined and a self-starter and able to work independently with a flexible work schedule.

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