Claims Processor I

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us. Residency in or relocation to Louisiana is preferred for all positions. Position Purpose Researches and verifies complex claims information to ensure the accurate and timely processing of claims. Enters all information needed to process claim. Identifies inconsistencies and makes necessary corrections. Accountable for complying with all laws and regulations associated with duties and responsibilities. Nature and Scope This role does not manage people This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS Necessary Contacts: In order to effectively fulfill this position, the Claims Processor I must be in contact with:Various internal departments and staff including, but not limited to, Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Membership and Billing, Administrative Services, and District Offices.Various external entities including, but not limited to, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, and other Plans. Qualifications Education High School Diploma or equivalent required Associate's is preferred Work Experience 1 year of related clerical or data entry is required A medical office or medical coding diploma can be used in lieu of the one year of experience Completion of the Medical Assistant, Coding & Insurance Pathway from BRCC, can be used in lieu of the one year of experience. Claims processing or claims coding experience is preferred Skills and Abilities Must be able to enter data at 4000 keystrokes per hour Medical coding training is preferred Must be able to demonstrate critical thinking and problem solving skills Familiarity with medical and health insurance terminology preferred Demonstrated verbal and written communication skills with the ability to interpret and communicate information with tact, diplomacy, patience and professionalism. Must demonstrate PC skills including Microsoft Office (e.g., Word, Excel, Outlook, etc.) Licenses and Certifications None Required Accountabilities and Essential Functions Reviews and corrects scanned claims documents upon receipt as well as enters coded information, checks claims for completeness and accuracy of information prior to final entry, while identifying and resolving inconsistences, and appropriately returns claims requesting missing information in accordance with established quantity, quality, and timeliness guidelines ensuring contract benefits are applied correctly, ultimately providing a high degree of customer satisfaction. Consistently researches procedural questions using supporting documentation while identifying incomplete adjudication instructions found within the supporting documentation, allowing for participatory suggestions for updating and correcting procedures, identifies training issues, and appropriately checking with management when necessary, to provide excellent quality in claims adjudication. Maintains and records information necessary for accurate recording and calculation of production, which include number of edits processed, hours worked, downtime and special projects assignments daily. This information is retained as historical data which is needed to continually refine and define the claims processor position as needed to ensure high customer satisfaction. Rejects, redirects misrouted or sends back claims when information is incomplete or inaccurate to facilitate timely processing ensuring that claims are processed according to departmental guidelines and assist with customer service. Researches procedural questions in training manual. Additional Accountabilities and Essential Functions The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions Perform other job-related duties as assigned, within your scope of responsibilities. Job duties are performed in a normal and clean office environment with normal noise levels. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required. Additional Information In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free. We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner. Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results. JOB CATEGORY: Insurance #J-18808-Ljbffr