FACETS Claims Processor

Job Description

Job Description

Location: Remote 
Reply at: View email address on us.fitly.work

FACETS SENIOR CLAIMS PROCESSOR 
Job Description:

• 5 Years Facets Claims Adjudication Experience

• The Claims Examiner must maintain production and inventory standards compliant with Claims Administration requirements

• High school diploma or equivalent required

• Must have 5+ years of relevant claim processing experience in healthcare industry (managed care or TPA Company) to support our clients

• Possess high productivity and quality standards within a claims processing automation environment

• Knowledge of CPT, HCPC, ICD-10 codes

• Knowledge of HMO, PPO, Medicare and Medicaid plans

• Knowledge of Medical terminology

• Computer with 2 Monitors

• High Speed Internet Connection

• Ability to work remote 8 hour day, Mon-Fri.

Responsibilities:

• The claims examiner is responsible for accurate and timely adjudication of claims for the Health Plans lines of business

• Primary duties include analysis and resolution of claims, including reviewing pended claims and manually resolving based on client specified direction and criteria, including third-party liability claims

• The claims examiner must be able to work independently, effectively prioritizing work in a production environment that frequently changes to meet production standards and contractual requirements

• Success in this position will be based on the individual's ability to effectively prioritize work, identify, and resolve complex concerns in a professional manner, and work in a team environment to achieve and maintain production and audit standards

• Timely and accurate processing and adjudication of all types of claims from assigned workflow queues

• Compliance with state, federal and contractual requirements to Claims Administration

• Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications

• Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review

• Ability to review and apply Plan directives and desktop procedures to claims, following step by step guidelines

• Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate

• Complete all mandatory claims training/refresher courses

• Actively participates and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives

• Complete all mandatory compliance and corporate training

• Must be able to adapt to a changing work priorities and requirements and perform other duties as directed to support the overall functions of Claims Administration and support of staff without boundaries within the Plan