Claims Processor

Claims Processor

As a Claims Processor, you will play a pivotal role in ensuring the efficiency and accuracy of claims processing within our organization. Your responsibilities will encompass a wide range of tasks, including year-end processing, managing adjustments, coordinating benefits, handling subrogation and high-dollar claims, processing Medicaid claims and complex appeals, and engaging in hospital audits.

The essential functions include, but are not limited to the following:

• Year-End Processing: Oversee and facilitate the year-end processing activities to ensure timely and accurate closure of claims records.
• Adjustments Management: Process adjustments to claims as needed, ensuring proper documentation and adherence to company policies and procedures.
• Coordination of Benefits: Manage coordination of benefits for claims.
• Subrogation and High-Dollar Claims: Handle subrogation claims and high-dollar claims, applying sound judgment and attention to detail in reviewing and processing these complex cases.
• Medicaid Claims and Complex Appeals: Process Medicaid claims and assist in handling complex appeals, demonstrating a thorough understanding of Medicaid regulations and procedures.
• Hospital Audits: Conduct hospital audits to ensure compliance with contractual agreements and regulatory requirements.
• Case Management Reports: Analyze case management reports and make sure they are filed to the correct member.

Minimum Qualifications (Knowledge, Skills, and Abilities)

• Bachelor's degree preferred, experience considered in lieu of degree.
• Minimum of 1-3 years of experience in claims processing or related field.
• Strong understanding of claims processing procedures, including familiarity with medical terminology and insurance policies
• Highly detail-oriented with a focus on accuracy and quality assurance in claims processing
• Strong analytical and problem-solving skills with the ability to identify root causes and develop solutions.
• Experience handling escalated issues and making sound decisions under pressure.

Other Details

Supervisory Responsibilities: None

Work Environment: The noise level in the work environment is usually low to moderate.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand, walk, sit, and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus.

Travel Requirements: None