Claims - Processor, Claims II

ROLE: Under general supervision, reviews and adjudicates paper/electronic claims. Determines proper handling and adjudication of claims following organizational policies and procedures.

ESSENTIAL FUNCTIONS:

55% Examines and resolves non-adjudicated claims to identify key elements of processing requirements based on contracts, policies and procedures. Process product or system-specific claims to ensure timely payments are generated and calculate deductibles and maximums as well as research and resolve pending claims. The Claims Processor also use automated system processes to send pending claims to ensure accurate completion according to medical policy, contracts, policies and procedures allowing timely considerations to be generated using multiple systems.

25% Does extensive research of procedures. May also apply training materials, emails and medical policy to ensure claims are processed correctly. Utilizes the quality team for assistance on unclear procedures and/or difficult claims and receives coaching from leadership. Ongoing developmental training to performing daily functions.

10% Completes productivity data daily that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design, financial planning, etc.

10% Assists Customer Service Reps by providing feedback and resolving issues and answering basic processing questions.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: High School Diploma or GED

Experience: 3 years claims experience required

Preferred Qualifications

Three years medical claims processing, billing or medical terminology experience. Experience using the FACETS Claims processing application

Knowledge, Skills and Abilities (KSAs)

Demonstrated communication skills both written and verbal.,

Demonstrated strong analytical skills,

Demonstrated knowledge and understanding of claims systems and processes.,

Demonstrated reading comprehension of materials provided to adjudicate claims

**Talteam Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.**