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About the Role
The Claims Adjudicator is responsible for adjudicating and adjusting medical and/or dental claims against established criteria, and in accordance with specific clients SPD’s maintaining goals in accuracy and productivity. The Claims Adjudicator is responsible to respond to client, member, and/or provider inquiries on claim status, benefit designs, and claim payments working in conjunction with the Customer Service Representative.
Responsibilities
- Adjudicate claims based on established policies and procedures for facility, professional, member submitted, pharmacy and dental claim edits, inclusive for both in and out-of-network benefits.
- Review vouchers/explanation of payments to identify and resolve claims related issues.
- Continually meet department performance measures as it relates to production, accuracy, knowledge of policy and procedure and timeliness of claims adjudication.
- Analyze, identify and research edits which demonstrate inconsistency in regard to policy, payment issues and coding issues.
- Maintain current contract, summary plan description and benefit knowledge.
- Adhere to departmental deadlines and turn-around times to be compliant with State and Federal regulations.
- Utilize critical thinking skills to process claims.
- Navigate through systems and applications to locate information specific to claim scenarios.
- Locate resources and read, interpret, and apply appropriate information to various claim scenarios.
- Identify and communicate process opportunities or improvements.
- Prioritize and manage claim processing workload efficiently.
- Communicate with other departments within Independent Health to resolve problems related to claims payment.
Requirements
- Six (6) months of medical claims processing/medical billing experience, customer service experience preferably in a healthcare related or social services setting; OR combination of experience.
- Knowledge of medical billing procedures; CPT and ICD-9 coding and medical terminology knowledge required.
- Proficiency with data entry skills and Microsoft Office products.
- Solid organizational skills with attention to detail and follow through.
- Good written, verbal and interpersonal communication skills.
- Demonstrated ability to effectively communicate with internal and external customers.
- Ability to work collaboratively.
- Flexibility to work additional hours as needed.
- Proven examples of displaying Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust.
Skills
- Data entry
- Microsoft Office
- Organizational skills
- Attention to detail
- Follow through
- Written communication
- Verbal communication
- Interpersonal communication
- Collaboration
- Critical thinking
- System navigation
- Resourcefulness
- Problem-solving
Location
- Williamsville
Work Type
- Hybrid
Experience Level
- 6 months experience
Education Level
- High school diploma
- Medical office assistant certificate preferred
- College degree preferred
Salary/Compensations
- $19.00 hourly
Benefits
- Scorecard incentive
- Full range of benefits
- Generous paid time off
About the Company
- We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.
Equal Opportunity
- As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.