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Reviews and adjudicates complex, sensitive, and specialized medical claims in accordance with established plan processing guidelines.
Functions as a subject matter expert by providing coaching, and offering guidance on escalated or technically challenging issues.
Supports customer service operations by addressing inquiries and resolving issues to ensure a positive member experience.
Reviews pre-specified claims and those that exceed specialist adjudication authority or processing expertise.
Applies medical necessity guidelines, determines coverage, verifies eligibility, identifies discrepancies, and implements cost-containment measures to support accurate claim adjudication.
Ensures compliance with all regulatory requirements and confirms that payments align with company policies and procedures.
Identifies and reports potential overpayments, underpayments, and other claim irregularities.
Performs claim rework calculations as needed.
Trains and mentors as needed to enhance team performance and technical proficiency.
Conducts outbound calls to obtain required information for claims or reconsideration requests.
Requirements:
Minimum of 18 months of medical claim processing experience with a health insurance payor or third-party administrator.
Proven success working in a high-volume, production-driven environment.
Demonstrated ability to manage multiple assignments with accuracy, efficiency, and attention to detail.
Self-Funding experience (Preferred)
DG system knowledge (Preferred)
High School Diploma required
Preferred Associates degree or equivalent work experience.
Benefits:
Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
