Claims Adjudicator III

UNITE HERE HEALTH•Oak Brook, IL

1d•Hybrid

About The Position

The Claims Adjudicator III position is responsible for successfully collaborating with the team Supervisor to provide direction and support to the team. This involves adjudicating complex medical, vision, dental, and short-term disability claims, as well as, escalated member and provider inquiries within established timeframes. The Claims Adjudicator Level III ensures claims are processed accurately according to the benefits as defined in the various Plan Documents. This position supports the team Supervisor in meeting departmental inventory metrics based on guidelines set forth by the Claims Department Management Team and the Department of Labor. The position is responsible for partnering with the PPO vendors to ensure that the financial responsibilities are met, which includes, but is not limited to the BlueCross and BlueShield incentive and daily claim rejects. This individual must possess excellent communication and organizational skills and can work independently. This position is relied upon as a subject matter expert for the Plan Documents and benefits for all Plan units managed by Aurora and associated regional offices. This position provides development and coaching to peers to ensure a high service quality.

Requirements

4 ~ 6 years of direct experience in a medical claim adjudication environment
Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
Working knowledge of plan design documents and pricing methodologies
Working knowledge and experience in medical claims adjudication, preferably in a multi-employer environment
Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA
High School Diploma or GED
Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook) required
Intermediate level Microsoft Excel skills
Manage competing deadlines and multiple projects in a fast-paced environment
Excellent communication skills (verbal and written) required
Exceptional time management, organizational and problem-solving skills
Ability to demonstrate good judgment and have excellent critical thinking skills
Ability to work independently with minimal supervision in a fast-paced environment

Nice To Haves

College degree preferred or equivalent work experience required

Responsibilities

Successfully investigate and respond to escalated inquiries from internal and external sources
Interacts with vendors and other UHH operational areas to resolve complex issues
Analyzes problems, identifies and develops alternative solutions, and implements recommendations
Triages claims and inquiries to determine if additional information or documentation from members, employers, providers and other insurance carriers is required
Verifies participant/dependent eligibility utilizing multiple internal systems
Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents to ensure accuracy
Responsible for comprehensive research and end to end processing of Medicare Secondary Payer (MSP) files, Personal Injury Protection (PIP) claims, Short Term Disability claims, Subrogation files, and complex claim adjustments
Requests overpayment refunds, maintains corresponding files and performs follow-up actions
Handles verbal and written inquiries received from internal and external customers
Identifies areas for process improvement and makes recommendations to management
Coordinates with team Senior and Supervisor to lead individual and/or team training sessions
Demonstrate necessary competence in technical, industry standard and soft skills to effectively support team
Acts as a subject matter expert providing support and mentoring to peers
Partners with other departmental areas on new and updated processes
Adjudicates claims and complex inqiuries according to established productivity and quality goals
Achieve individual established goals in order to meet or exceed departmental metrics
Set goals and achieve measurable results
Contributes ideas to plans and achieving department goals
Exemplifies the Fund’s BETTER Values and Professional Effectiveness Dimensions in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
Performs other duties as assigned within the scope of responsibilities and requirements of the job
Performs Essential Job Functions and Duties with or without reasonable accommodation