POSITION SUMMARY 

As a Claims Processor, you will play a pivotal role in ensuring the efficiency and accuracy of claims processing within our organization. Your responsibilities will encompass a wide range of tasks, including year-end processing, managing adjustments, coordinating benefits, handling subrogation and high-dollar claims, processing Medicaid claims and complex appeals, and engaging in hospital audits. 

ESSENTIAL DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to the following:

• Year-End Processing: Oversee and facilitate the year-end processing activities to ensure timely and accurate closure of claims records. 
• Adjustments Management: Process adjustments to claims as needed, ensuring proper documentation and adherence to company policies and procedures. 
• Coordination of Benefits: Manage coordination of benefits for claims. 
• Subrogation and High-Dollar Claims: Handle subrogation claims and high-dollar claims, applying sound judgment and attention to detail in reviewing and processing these complex cases. 
• Medicaid Claims and Complex Appeals: Process Medicaid claims and assist in handling complex appeals, demonstrating a thorough understanding of Medicaid regulations and procedures. 
• Hospital Audits: Conduct hospital audits to ensure compliance with contractual agreements and regulatory requirements. 
• Case Management Reports: Analyze case management reports and make sure they are filed to the correct member.

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)

• Bachelor's degree preferred, experience considered in lieu of degree.
• Minimum of 1-3 years of experience in claims processing or related field. 
• Strong understanding of claims processing procedures, including familiarity with medical terminology and insurance policies 
• Highly detail-oriented with a focus on accuracy and quality assurance in claims processing 
• Strong analytical and problem-solving skills with the ability to identify root causes and develop solutions. 
• Experience handling escalated issues and making sound decisions under pressure.

OTHER DETAILS

Supervisory Responsibilities

None

Work Environment

The noise level in the work environment is usually low to moderate.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand, walk, sit, and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus.

Travel Requirements

None

NOTE

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise.

The Company complies with employment regulations as they apply to the location of service.