Claims Processor

Highmark Inc. 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 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 Pay Range Minimum: $19.39 Maximum: $24.19 Equal Opportunity Statement 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. #J-18808-Ljbffr