Claims Adjudicator

Responsibilities Adjudicate claims based on established policies and procedures for facility, professional, member submitted, pharmacy and dental claim edits. Review vouchers/explanation of payments to identify and resolve claims related issues. Continually meet department performance measures as it relates to production, accuracy, knowledge of policy and procedure and timeliness of claims adjudication. Analyze, identify and research, as needed, edits which demonstrate inconsistency in regard to policy, payment issues and coding issues. Maintain current contract, summary plan description and benefit knowledge. Ability to adhere to departmental deadlines and turn-around times, to be compliant with State and Federal regulations. Effectively utilize critical thinking skills to process claims. Efficiently navigate through systems and applications to locate information specific to claim scenarios. Accurately locate resources and read, interpret, and apply appropriate information to various claim scenarios. Identify and communicate process opportunities or improvements. Prioritize and manage claim processing workload in an efficient manner. Effective written, verbal and interpersonal communication with other departments within Independent Health to resolve problems related to claims payment. Requirements High school diploma required; medical office assistant certificate and/or college degree preferred. Six (6) months of medical claims processing/medical billing experience, customer service experience preferably in a healthcare related or social services setting; OR combination of experience. Knowledge of medical billing procedures; CPT and ICD-9 coding and medical terminology knowledge required. Proficiency with data entry skills and Microsoft Office products. Solid organizational skills with attention to detail and follow through. Good written, verbal and interpersonal communication skills. Demonstrated ability to effectively communicate with internal and external customers. Must be able to work collaboratively. Flexibility to work additional hours as needed. Proven examples of displaying Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust. Core Competencies Demonstrates expertise in medical claims processing, including knowledge of CPT and ICD-9 coding, while effectively communicating with internal and external customers. Exhibits strong organizational skills and critical thinking abilities to ensure compliance with policies and regulations. #J-18808-Ljbffr Jobtailor