Associate Claims Representative
About The Position
Responsible for processing health insurance claims submitted via paper or electronically by providers and members. Ability to release health insurance claims for payment according to the defined workflows. Validates health insurance claims with an understanding of health insurance cost sharing, limitations, and exclusions. Reviews claims for completeness and accuracy, apply medical necessity and/or eligibility guidelines to determine coverage, work assigned pend and error reports, determine the benefit level to be paid according to the summary plan language, release health insurance claims for payment, and prepare requests for additional information as needed. Responds promptly to requests for information from other Sanford Health Plan departments. Refers complex claims to Senior and/or Lead Claims Representatives. Requires analytical ability and keen attention to detail with a high degree of accuracy in work. Understands accumulators for accurate monitoring of maximum out of pocket expenses for claims processing. Must have demonstrable computer literacy. Perseverance in completing work with a desire to learn is necessary. Must maintain confidentiality. Basic knowledge of Microsoft Office. Other duties as assigned.
Requirements
- High school diploma or equivalent required.
- One year of applicable experience required.
- Demonstrable computer literacy.
- Basic knowledge of Microsoft Office.
- Must maintain confidentiality.
Nice To Haves
- Some college level course work preferred.
- A minimum of one year of medical claims processing experience is preferred.
Responsibilities
- Process health insurance claims submitted via paper or electronically by providers and members.
- Release health insurance claims for payment according to defined workflows.
- Validate health insurance claims with an understanding of health insurance cost sharing, limitations, and exclusions.
- Review claims for completeness and accuracy.
- Apply medical necessity and/or eligibility guidelines to determine coverage.
- Work assigned pend and error reports.
- Determine the benefit level to be paid according to the summary plan language.
- Prepare requests for additional information as needed.
- Respond promptly to requests for information from other Sanford Health Plan departments.
- Refer complex claims to Senior and/or Lead Claims Representatives.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
