Inventory Claim Processor

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.
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. 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.
• ​High School Diploma/GED

1 year of claims processing experience
~ Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
Ability to use mathematics to adjudicate claims.
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):
Travel Requirement:
Office-based
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. 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.
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