Claims - Processor, Claims I

PURPOSE:
Under direct supervision, reviews and adjudicates paper/electronic claims. Determines proper handling and adjudication of claims following organizational policies and procedures.


ESSENTIAL FUNCTIONS:
60% Examines and resolves non-adjudicated claims to identify key elements of processing requirements based on contracts, policies and procedures. Process product or system-specific claims to ensure timely payments are generated and calculate deductibles and maximums as well as research and resolve pending claims. The Claims Processor also use automated system processes to send pending claims to ensure accurate completion according to medical policy, contracts, policies and procedures allowing timely considerations to be generated using multiple systems.


25% Completes research of procedures. Applies training materials, correspondence and medical policies to ensure claims are processed accurately. Partners with Quality team for clarity on procedures and/or difficult claims and receives coaching from leadership. Required participation in ongoing developmental training to performing daily functions.


10% Completes productivity daily data that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design and financial planning, etc.


5% Collaborates with multiple departments providing feedback and resolving issues and answering basic processing questions.


Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.


Education Level: High School Diploma or GED


Experience: less than one year experience processing claim documents


Preferred Qualifications
1-3 years Claims processing, billing, or medical terminology experience


Knowledge, Skills and Abilities (KSAs)
Demonstrated analytical skills, Proficient
Demonstrated reading comprehension and ability to follow directions provided, Proficient
Basic written/oral communication skills , Proficient
Demonstrated ability to navigate computer applications , Proficient


The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.