They will be responsible and accountable to support organizational goals and follow all processes with a focus on Claims Adjudication.
This Claims Adjudication role will include reviewing and examining claims based on provider and health plan contractual agreements, claims processing guidelines, coordinating benefits (COB) with other health insurance, reviewing duplicate claims, and manual processing to ensure the accurate and timely processing of all claims.
They will work as part of a team to meet Service Level Agreements (SLA’s) in accordance with client contracts, established departmental and governmental guidelines.
Bachelor’s Degree in Business Administration, Health Care or another related field
Minimum 2-3 years of experience in US Healthcare that directly aligns with the specific responsibilities for this position
Well-versed with HMO Plans
Knowledge of Medi-Cal and Medicare are a plus
Core Competencies : Ethics and Values, Customer Focus, Action-Oriented, learning on the Fly, Manage / Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
Computer Proficiency (MS Word, MS Excel)
Minimum typing speed 40 WPM
Strong communication skills (English verbal and written), and technical skills to use for Claims processing
Must have a thorough understanding of claims operations, including, but not limited to, prior roles as adjuster / examiner, claims operations, or equivalent
Essential Functions of Job
Responsible for following all departmental policies and procedures.
Receive direction and training on extensive claim adjudication.
Work and manage claims first in and first out basis.
Using DOFR-Division of Financial Responsibility Identify claims that are not our clients financial risk.
Verify patient’s accounts for eligibility and benefits.
Read, interpret and summarize provider contracts.
Validate paper claims data against system data for accurate data capture.
Adjudicate claims in accordance with department policies and procedures and other business rules.
Meets production and quality standards as established by Client.
All other duties as assigned