Claims Adjudication Associate

Judi Health•Charlotte, NC

2d•Hybrid

About The Position

Judi Health is seeking a self-driven Claims Adjudication Associate to support the Medical claims adjudication workflow for JUDI Health, our enterprise health platform. In year one, this individual will train on the JUDI Medical adjudication system. This individual will be responsible for maintaining the operational adjudication process, member, and provider escalated inquiry management, subrogation, stop-loss, recoupment and adjustment flows, and adhering to standard and contractual claims processing SLAs. In year two, this individual will be responsible for managing and servicing new and existing clients of JUDI’s Medical Claims Adjudication platform. This individual will be expected to maintain an in-depth understanding of the evolving capabilities of JUDI and our medical network support and client base. Exceptional communication skills and attention to detail are critical for communicating with internal and external stakeholders to build holistic support for medical claims processing.

Requirements

Bachelors degree strongly preferred
Experience managing a team of direct reports
1+ years of work experience at a health plan, claims adjudicator, or TPA
Well-versed in Benefit determinations
Well-versed in impact of claims processing and adjudication in regards to COB, Adjustments, Appeals, and member/provider inquiries
Act as a patient advocate, protecting privacy and confidentiality issues.
Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables
Exceptional project / time management, prioritization, and organizational skills to ensure customer satisfaction
Ability to shift between competing priorities and meet organizational goals
Proficient in Microsoft office Suite and willing to adapt to software such as Jira, Miro, Confluence, Github, and AWS Redshift
Excellent verbal, written, interpersonal and presentation skills
Ability to work effectively with virtual teams

Nice To Haves

Medicare/Medicaid experience preferred

Responsibilities

Review, assess, and make decisions on medical claims submitted by networks, claimants, or other parties.
Provide support to Customer Care representatives in relation to claims and benefits questions from Members and Providers.
Manually adjudicate claims received via 837 EDI file, HIPAA 1500 or UB-04 forms, or direct member reimbursement submissions via superbill submission.
Adhere to standard SLA’s regarding number or percentage of claims processed per day
Assist in management of claims related mail workflows including Appeals, subrogation, payments, and stop-loss.
Build and maintain trusting relationships with clients through superior customer service.
Assist in communications throughout the implementation process, including detailed and strategic guidance for adjudication infrastructure, processing, reporting, inquiry management, and complex claim situations/requests.
Proactively identify execution risks and mitigation strategies.
Identify and drive efficiencies to automate adjudication flows and reduce risk.
Responsible for adherence to the Judi Health Code of Conduct including reporting of noncompliance.