Claim Technician

HCSC•Albuquerque, NM

3d•Hybrid

About The Position

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. BASIC FUNCTION Under supervision, this position is responsible for processing complex claims requiring further investigation, including coordination of benefits and resolving pended claims. The Claim Technician is responsible for reviewing, processing, and adjudicating healthcare claims accurately and efficiently in accordance with company policies, payer guidelines, and regulatory requirements. This role investigates claim discrepancies, researches denials, verifies member and provider information, and ensures timely claim resolution. The Claims Technician also collaborates with internal departments, providers, and members to resolve claim issues while maintaining high standards of accuracy, productivity, compliance, and customer service. The ideal candidate demonstrates strong analytical skills, attention to detail, and knowledge of healthcare claims processing, medical terminology, and applicable regulations, including HIPAA. NOTE: there is a mandatory six-week onsite training with strict attendance requirements which occurs Monday-Friday (8am to 5pm). Upon successful completion of this training, work from home provisions will be established.

Requirements

High School diploma or GED.
Solid data entry and/or typing experience.
Proficiency in Microsoft Office Suite, including Excel for data review and reporting.
Clear and concise written and verbal communication skills.
Experience processing medical claims with the ability to manage high-volume workloads while maintaining quality metrics.
Strong attention to detail, problem-solving, and organizational skills.

Nice To Haves

Trained on the six or eight-week Blue Chip claims processing system or have the ability to fully complete the six or eight-week Blue Chip Training class.
Knowledge of medical terminology and CPT, HCPCS, and ICD9 coding.
Knowledge of coordination of benefits principles and terminology.
Familiarity with claims adjudication systems and healthcare payer processes.
Experience with multi-tasking and prioritizing.

Responsibilities

Process complex claims in various queues.
Conduct research and investigation into missing information, make phone calls to providers (as necessary), access resource materials and support files in order to process and adjudicate claims timely and accurately.
Resolve complex pended claims, duplicate claims and adjustments.
Process claims, involving communications with participating plans and/or Service Units.
Resolve various issues.
Research and identify other insurance, Medicare, Medicaid and update patient file as needed.
Coordinate benefits; request explanation of benefits as needed.
Maintain a working understanding of medical terminology and CPT, HCPCS, and ICD9 coding.
Maintain knowledge related to specific contracts.
Read appropriate files in IMAGE and apply information to claims as needed using the Financial Suspense System (FSS).
Learn and maintain knowledge of DOL ERISA and prompt pay legislation.
Periodic overtime may be required at the sole discretion of the employer based on business need.