Claims Processor

Company : Highmark Inc. Job Description : JOB SUMMARY This job is responsible for screening, reviewing, evaluating online entry, correcting errors and/or performing quality control review and final adjudication of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Reviews processed claims and inquiries to determine corrective action including adjusting claims as necessary and takes the corrective action steps using enrollment, benefit and historical claim processing information; may coordinate benefits and interact with customers. Responsible for the timely and accurate completion of claims adjustments which could be a result of internal/external audits, member/provider phone calls, other insurance information received, appeals, and system changes, etc.; provides technical assistance in researching and resolving inquiries. ESSENTIAL RESPONSIBILITIES Receives and processes claims to include entering/verifying claims data; determines if claim information is complete and correct. Resolves claim edits, reviews history records and determines benefit eligibility for service. Reviews payment levels to arrive at final payment determination. Elevates issues to next level of supervision as appropriate and ensures a professional line of communication is maintained with internal and external customers. Meets all production and quality standards, ensuring timeliness and accuracy of all work given by support staff/management. Maintains accurate records, including timekeeping records and attends all required training classes. Other duties as assigned or requested. EDUCATION Required High School Diploma/GED Substitutions None Preferred None EXPERIENCE Required 1 year of related experience Preferred 1 year of claims processing experience Inquiry resolution system, OCWA, Oscar, Outlook experience LICENSES or CERTIFICATIONS Required None Preferred None SKILLS Strong verbal and written communication skills. Ability to take direction and to navigate through multiple systems simultaneously. Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records. Ability to use mathematics to adjudicate claims. Ability to solve problems within pre-defined methods and guidelines. Knowledge of operating systems specific to claim processing. Ability to review claims and analyze critical data. Reading benefits, investigating edits and making benefit determinations as required in adjusting and adjudicating most types of claims. Researches and finalizes claims, adjustments, inquiries and reports as required. Language (Other than English): None Travel Requirement: 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-based Teaches / trains others regularly Never Travel regularly from the office to various work sites or from site-to-site Never Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Never Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $19.39 Pay Range Maximum: $24.19 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at View email address on click.appcast.io California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.