Claims Adjudicator

Claims Adjudicator

The Claims Adjudicator is responsible for adjudicating and adjusting medical and/or dental claims against established criteria, and in accordance with specific clients SPD's maintaining goals in accuracy and productivity. The Claims Adjudicator is responsible to respond to client, member, and/or provider inquiries on claim status, benefit designs, and claim payments working in conjunction with the Customer Service Representative.

High school diploma required; medical office assistant certificate and/or college degree preferred.

Six (6) months of medical claims processing/medical billing experience, customer service experience preferably in a healthcare related or social services setting; OR combination of experience.

Knowledge of medical billing procedures; CPT and ICD-9 coding and medical terminology knowledge required.

Proficiency with data entry skills and Microsoft Office products.

Solid organizational skills with attention to detail and follow through.

Good written, verbal and interpersonal communication skills. Demonstrated ability to effectively communicate with internal and external customers.

Must be able to work collaboratively. Flexibility to work additional hours as needed.

Proven examples of displaying Nova's Core 4: Act with Passion, Work Together, Be Accountable, Build Trust.

Adjudicate claims based on established policies and procedures for facility, professional, member submitted, pharmacy and dental claim edits. This is inclusive for both in and out-of-network benefits.

Review vouchers/explanation of payments to identify and resolve claims related issues.

Continually meet department performance measures as it relates to production, accuracy, knowledge of policy and procedure and timeliness of claims adjudication.

Analyze, identify and research, as needed, edits which demonstrate inconsistency in regard to policy, payment issues and coding issues.

Maintain current contract, summary plan description and benefit knowledge.

Ability to adhere to departmental deadlines and turn-around times, to be compliant with State and Federal regulations.

Effectively utilize critical thinking skills to process claims.

Efficiently navigate through systems and applications to locate information specific to claim scenarios.

Accurately locate resources and read, interpret, and apply appropriate information to various claim scenarios.

Identify and communicate process opportunities or improvements.

Prioritize and manage claim processing workload in an efficient manner.

Effective written, verbal and interpersonal communication with other departments within Independent Health to resolve problems related to claims payment.

Immigration or work visa sponsorship will not be provided for this position Hiring Compensation Range: $18.00 hourly

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.