Claims Adjudicator II

UNITE HERE HEALTH•Oak Brook, IL

1d•Remote

About The Position

UNITE HERE HEALTH serves 200,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity! The Claims Adjudicator II position will receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries.

Requirements

3 ~ 5 years of direct experience minimum in a medical claim adjudication environment
Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
Experience with eligibility verification, medical coding, coordination of benefits, and subrogation and it’s related processes
Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes

Nice To Haves

Fluency (speak and write) in Spanish

Responsibilities

Screens claims for completeness of necessary information
Verifies participant/dependent eligibility
Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
Codes basic information and selects codes to determine payment liability amount
Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
Handles the end to end process of Medicare Secondary Payer (MSP) files
Processes Personal Injury Protection (PIP) claims
Requests overpayment refunds, maintains corresponding files and performs follow-up actions
Handles verbal and written inquiries received from internal and external customers
Processes Short Term Disability claims
Adjudicates claims according to established productivity and quality goals
Achieve individual established goals in order to meet or exceed departmental metrics