Claims Adjudicator II

Unite Here Health • Aurora, IL

416d • $42,245 - $51,834 • Remote

About The Position

The Claims Adjudicator II position is responsible for processing and adjudicating various types of claims, including medical, disability, vision, and dental claims. This role involves verifying claim data, determining eligibility, and ensuring compliance with established guidelines and timeframes. The position requires the use of multiple systems to manage claims and respond to inquiries from participants and providers.

Requirements

• 3 ~ 5 years of direct experience minimum in an insurance setting as an adjudicator
• 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
• Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes
• Working knowledge and experience in Subrogation and its related processes
• Intermediate level system(s) skills in Javelina claims system or other similar system preferred

Nice To Haves

• Preferred 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
• 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

Benefits

• Medical
• Dental
• Vision
• Paid Time-Off (PTO)
• Paid Holidays
• 401(k)
• Pension
• Short- & Long-term Disability
• Life Insurance
• AD&D
• Flexible Spending Accounts (healthcare & dependent care)
• Commuter Transit
• Tuition Assistance
• Employee Assistance Program (EAP)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Personal and Laundry Services
• Education Level: No Education Listed