Job Description
Claims Adjuster JOB SUMMARY: Analyze claims to determine the extent of insurance carrier liability. Interpret contract benefits in accordance with specific claims processing guidelines. Receive, organize and make daily use of information regarding benefits, contract coverage, and policy decisions. Coordinate daily workflow to coincide with check cycle days to meet all service guarantees. Maintain external contacts with policyholders, providers of service, agents, attorneys and other carriers as well as internal contacts with peers, management, and other support areas with a positive and professional approach. ESSENTIAL DUTIES & RESPONSIBILITIES (other duties may be assigned as necessary): Examine/perform/research & make decisions necessary to properly adjudicate claims and written inquiries. Interpret contract benefits in accordance with specific claim processing guidelines. Understand broad strategic concept of our business and link these to the day-to-day business functions of claims processing. Minimal external contact with providers/agents/policyholders. QUALIFICATIONS: 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. Good oral and written communication skills Good PC application skills and typing to 30 wpm with accuracy and clarity of content. Previous health/Medicare/prescription claims adjudication experience a plus. Must have organizational and decision making skills. Team centered with excellent work ethic and reliability. Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims. Familiarity with medical terminology, procedure and diagnosis codes preferred. Familiarity with Qiclink software a plus. Ability to calculate figures and co-insurance amounts. Ability to read and interpret EOB’s. Ability to multitask, prioritize, problem-solve and effectively adapt to a fast-paced, changing environment in order to comply with service guarantees. Must be able to work independently and meet quality and production standards. Must have clear understanding of the policy benefits and procedures within the Claims unit. Honesty, as well as respect, for the company and its policies & procedures is crucial. EDUCATION and/or EXPERIENCE REQUIRED: High School diploma or GED equivalent. Minimum of one (1) year related experience required. Experience in medical/insurance preferred. Experience with Medicare Supplement preferred. #talrooprofessional
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