Job Summary

Encodes, analyzes, and adjudicates routine medical, dental, vision, and prescription drug claims. Follows up on non-routine or incomplete claims. Meets strict performance standards set by employers and contracted providers. Works with other carriers to establish liability and level of coverage and coordinate benefits – primarily related to workers compensation, auto, insurance, and dual health coverage. Recommends changes or improvements to claims processing systems and information system interfaces. Provides telephone coverage to member and provider services on issues related to eligibility, coverage, and claims.

Job Responsibilities

Process, encode, analyze and adjudicate manual paper claims and EDI claims according to individual employer plan document/SPD (medical, dental, vision, HRA, FSA, & HSA claims). (Requirement of 150 claims per day with 99% or above accuracy for an experienced processor)

Provide member services information via phone calls and emails on claim status, benefits, coverage eligibility, and COBRA admin. (Requirement of at least 50 calls per day for an experienced Customer Service representative)

Follow-up on non-routine or incomplete claims, calling providers or requesting medical records for review when necessary.

Coordinate benefits with other providers of insurance, including subrogation.

File reviews and letters to members, including spreadsheets for claims utilization and out-of-pocket reviews.

Schedules completion of unclear claims according to contractual deadlines in accordance with PPO contract, stoploss contract, employer turn-around time guarantees, and funding request timelines.

Displays ability to work with highly confidential information.

Calculate overpayment requests in accordance with PPO discounts and employer benefits.

Organize, scan, and file TPA Claims.

Other duties as assigned or required.

Requirements

Education: High school diploma or equivalent with additional course work and one to two years health care claims experience, preferably with managed care.

Required Experience: Good computer skills in Microsoft Office preferred; accuracy and speed of data entry; knowledge of third party liability, COB, and subrogation issues; medical terminology and ICD-10, CPT and UB92.

Specialized courses, certifications, or trainings: Experience in Claims Processing or Managed Care; coding knowledge helpful

Populations Served:

While performing this job, the employee may care for patients in the following age groups.

While performing this job, the employee does not care for patients in the following age groups.