Claim Adjuster

MedPro Group • Springfield, MA

21d • $26 - $31 • Hybrid

About The Position

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace. Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market. Join our rapidly growing and fast paced health insurance organization in the Springfield area. The Claim Adjuster is responsible for fully understanding Wellfleet’s policies and procedures, deep knowledge of the claim process with the ability to process and adjust claims. The incumbent is responsible for implementation, auditing, and execution of compliance activities as they relate to claims. They will work closely with the Compliance Team to assess compliance risks and controls and implement and communicate new regulations that affect the claims team. The incumbent in this position is responsible for quality and timely adjudication of claims (medical accident, dental, life, etc.) in support of all product lines administered by Wellfleet. Must possess good communication skills, be detail oriented problem solver with good time management skills.

Requirements

• A minimum of three years’ health care claim processing experience required
• Understanding of medical billing codes
• Solid understanding of Wellfleet’s policies and procedures
• Strong organizational skills and attention to detail
• Strong written and verbal communication skills
• Ability to work in a fast-paced environment, think quickly, meet deadlines, and adapt to various situations
• Ability to understand complex problems, identify root causes, and remain goal-oriented within a dynamic environment
• Ability to prioritize multiple work assignments simultaneously
• Exhibits strong work ethic
• Strong analytical skills, with the ability to effectively identify, communicate, and address potential issues
• Ability to work independently and as a team player
• Ability to work effectively with peers, as well as other business areas of the organization
• Strong commitment to compliance & ethics

Responsibilities

• Be proficient in navigating and processing claim in the LuminX claim system
• Have an in depth understanding of the claim adjudication process:
• Process claims in accordance with the plan document in a timely and accurate manner
• Perform detailed analysis of medical treatment submitted for payment
• Investigate and administer the terms of coverage
• Handle claim adjustments
• Perform root cause analysis on payment errors, run impact reports and recommend fixes
• Maintain a working knowledge of State/Federal insurance regulations and mandates
• Maintain product/system knowledge and be a subject matter expert
• Able to work independently with minimal questions and find resolution to problems
• Complete understanding of the basics of insurance
• Able to process any health insurance product serviced at Wellfleet
• Dependable and available as needed to ensure operational needs are met
• Respond to email inquiries professionally and promptly
• Demonstrate the ability to comprehend and interpret documents, such as training manuals, correspondence, brochures, policies etc.
• Respond to customer service inquiry forms requiring adjustments within 2 business days
• Demonstrate a solid understanding of COB, Subrogation and HIPAA Privacy
• Have the ability to multitask and adhere to deadlines and turnaround times
• Serve as an informational resource to other employees
• Ability to handle special projects
• Follow workflows as approved by management
• Communicate issues, concerns etc. to supervisor
• Perform other duties as assigned, or as situations dictates

Benefits

• Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 101-250 employees