Job Requirements
POSITION SUMMARY:
To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by being responsible and accountable for the accurate and timely claims processing of all claim types. Which includes keying, auditing, processing and sending issues between departments. Claims processed with a high level of detailed quality and in accordance with claims payment policy and by the terms of our customer/provider contractual agreements.
PRIMARY ACCOUNTABILITIES:
Engagement:
- Communicate identified issues with claims and claims processes to the Lead within the claims department.
- Actively participate and collaborate with entire department and continuously improve workflows and performance.
- Effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions and employing active listening techniques.
- Continuously adapt to and positively influence change by accepting feedback and capitalizing upon opportunities to improve.
Quality/No Harm:
- Adjudicate claims. Ensuring claims handled appropriately with claim pertinent and correct information for processing. The member is eligible for coverage on the date(s) of service; services have the required referral/authorizations; accurate final claims adjudication/adjustments by using on-line computer claims payment system, which includes research on previously processed claims when needed; identify billing patterns, processing errors and/or system issues that inhibit the final adjudication of claims.
- Meet the performance goals established for the position in the areas of: efficiency, accuracy, productivity, quality and attendance.
- Utilize Claims Department policies & procedures, Support Point, workflows and manuals to meet departmental production and quality metrics.
- Follow processes and work independently to ensure ability to meet or exceed Key Performance Indicators (attainment and/or productivity targets) aligned with specific function/application.
Stewardship:
- Track and report on any overpayment recovery utilizing refund process.
- Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMC/Medicare guidelines, benefit plan documents/certificates).
- Insure manually pricing is accurate and appropriate.
Customer Experience:
- Research claims for completion and appropriateness.
- Review and handle rejected claims as necessary.
- Ensure timely, accurate claim processing services to clients.
Work Experience
QUALIFICATIONS REQUIRED:
- High school diploma with 6 to 12 months of vocation/post high school education or equivalent work experience.
- Minimum of 6 months of healthcare/dental clinical, customer service, billing, etc.
- Proficient in Microsoft Office including: Microsoft Word; Outlook and Excel.
- Excellent oral and written communication skills.
- Proficient in Microsoft Office including: Microsoft Word; Excel and Access.
PHYSICAL DEMANDS:
- Ability to work eight or more hours at a desk using computers.
- Ability to handle large volume of paperwork in an organized manner.
- Staying organized and effectively prioritizing work and managing time.
MENTAL DEMANDS:
- Ability to work in often stressful environments.
- Strong Analytical and critical thinking skills evidenced by the ability to analyze and interpret information quickly and accurately.
- Maintaining a high level of motivation, initiative and accountability.
- Handling conflict in a productive manner.
- Working effectively with all levels of employees and management.
COMPETENCY ASSESSMENT/SKILLS CHECKLIST:
- To attend training and complete class for Examiner 1.
- Required to pass final testing from training.
- Consistently achieve and maintain productivity, quality and attendance requirements.
Benefits
ABOUT HEALTH FIRST
At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.
Schedule : Full-Time
Shift Times : 730am_400pm