Medical Claims Adjuster I

Job Description

This position plays a critical role in PEHP's efforts to serve and create value for our members by processing a variety of medical claims proficiently and timely. The position includes a variety of professional duties related to processing claims. Successful performance for this position requires an attention to detail, the ability to learn complex claims processes while managing multiple diverse tasks, and a high level of commitment and dependability.

Essential Job Functions And Duties

• Receives and enters medical and/or Medicare claims for payment under medical and/or Medicare Supplement plans.
• Reviews claims for accuracy and completeness, verifies coverage and eligibility of patient.
• Adjudicates routine and complex claims according to established policy guidelines.
• Processes coordination of benefits on Medical and Dental claims.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality.
• Performs other related duties as required.

Required Experience

Education and Experience

High School diploma and one (1) year of work experience.

Specific experience in claims processing, and various administrative functions is preferred, or an equivalent combination of education and experience.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Requires working knowledge of:

• Intricacies related to medical, dental, pharmacy, and Medicare Supplement claims.
• Procedures and processes; intricacies related to medical, mental health and chiropractic claims
• CPT, ICD-10-CM and HCPC's coding and medical terminology
• Various office management systems related to alpha and numeric record keeping
• Personal computer operations and various program applications
• Some knowledge of 10 key operation
• Mathematical skills

Must possess excellent communication skills:

• Interpersonal communication skills; telephone etiquette
• Communicate effectively verbally and in writing

Must have the ability to:

• Analyze a variety of routine claims management issues and problems and make routine corrections
• Maintain a strong attention to detail.
• Follow written and verbal instructions.
• Prioritize work, multi-task, follow through with assignments, and perform within deadlines.
• Deal effectively with stress caused by workload and time deadlines.
• Work well in a team environment as well as independently.
• Follow through with assignments.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.