Job description
Summary
This position reports to the VP Claims and is responsible for each respective client's medical claims adjudication and handling of appeals.
Qualification Requirements
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. Experience with the Luminx claims processing system is preferable but not required.
Minimum Qualifications
- High school graduate or General Education Degree (GED)
- At least 2 years of related experience
Knowledge, Skills and Abilities
- Excellent verbal and written communication skills required.
- Must possess proficiency in Microsoft products, particularly Excel and Word.
- Ability to utilize the available time to organize and complete work within given deadlines.
- Ability to work independently with minimal supervision.
- Ability to communicate in writing clearly and concisely
- Ability to pay attention to the minute details of a project or task.
Essential Functions
- Responsible for all assigned clients and their members in the area of claims adjudication.
- Must read and interpret language in respective client’s Plan Document to ensure accuracy in processing claims.
- Rely on Claims Processing Manual, Trilogy and written Procedures to determine accuracy of coverage for services billed
- Answer emails within 24 hours responding to members/providers/clients, etc.
- Contact doctors, hospitals and claimants when investigation of claims is necessary
- Maintain a minimum of 98% overall (financial and non-financial) quality accuracy on claims
- Determine any correlation in the Coordination of Benefits (COB) on each claim, verify information and coordinate calculation of benefits before issuing payments
- Keep open communications with Medical Claims Director and/or Medical Team Leader on any unusual claims
- Review and investigate appeals. Forward appeals and related documentation to Team Leader or designated person for review.
- Perform any other duties as delegated by the VP, Medical Claims/Medical Team Leader
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