Claims Processor II

MISSION
Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.

VALUES
HealthOne is guided by a cultural framework that embodies our values and drives our decisions.


As a company our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. We fulfill our purpose by filtering our decisions through a PRIORITIES lens of asking, "Is what we are about to do ethical, empathetic, economical, and efficient?". By caring for PEOPLE, we are welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.

HealthOne seeks individuals with integrity and heart to embody our values. Whether you're starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.

JOB PURPOSE
The Claims Processor II is responsible for accurate and timely processing of both professional and institutional medical claims pended for manual adjudication in assigned Workflow roles. The Claims Processor II will accurately interpret benefit and policy provisions applicable to fully-insured plan members and review claims to determine coverage based on contract, provider status, and claims processing guidelines. The incumbent must meet quality and productivity standards.

ESSENTIAL JOB DUTIES
Reviews and adjudicates claims up to specified dollar limits
Processes claims within performance guidelines of the department, including quality and timeliness
Works with and understands Company benefit plans
Understands provider contracts
Examines and interprets all relevant documents included with the claims
Responds to claim-specific questions, as applicable
Partners with leadership on any questionable claim activity
Understands logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.)
Determines accurate payment criteria for clearing pended claims based on defined Policy and Procedures
Researches claim edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for claims
Works high volume of repetitive claims
Identifies claims with inaccurate data or claims that require review by appropriate team members
Contributes positively as a team player
Completes special projects as assigned and supports other Claims Department team members in assigned projects
Complies with all departmental and Company policies and procedures
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned

QUALIFICATIONS
High School Diploma or GED required
Associates or Bachelor's Degree preferred
A minimum of one year experience in claims processing required, must include Professional and Institutional processing; previous experience in medical billing and coding required if no claims processing experience
Knowledge of ICD-10, CPT4, DRG, HCPCS codes, medical terminology, EDI and HIPAA protocols preferred
Knowledge of UB and HCFA 1500 forms
Certified Professional Coder (CPC) preferred
Experience with Word and Excel


PHYSICAL REQUIREMENTS
Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

BENEFITS
401K (4% Match, Immediate Vesting)
Accident insurance
Competitive salary
Critical Illness Insurance
Dental Insurance
Employee Assistance Program
Flexible Spending Account
Health & Wellness Program
Health Savings Account
Life & AD&D Insurance
Long Term Disability
Medical Insurance
Paid Time Off
Pet Insurance
Short Term Disability
Vision Insurance


PRE-EMPLOYMENT SCREENING
Drug Screen and Background Check Required

HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status or any other status protected by state or federal law.