Claims Adjudicator

Independent Health•Buffalo, NY

19d•Hybrid

About The Position

The Claims Adjudicator adjudicates and adjusts medical and/or dental claims using established criteria and specific client summary plan descriptions (SPDs), while meeting accuracy and productivity goals. The role also responds to client, member, and provider inquiries about claim status, benefit designs, and claim payments in coordination with Customer Service Representatives. This is a hybrid position requiring onsite attendance at the Williamsville location. Immigration or work visa sponsorship is not available. The hiring compensation range is $19.00 per hour. Associates may also be eligible for a scorecard incentive, benefits, and paid time off. Compensation may vary based on factors including skills, education, location, and experience.

Requirements

High school diploma required.
Six months of medical claims processing or medical billing experience, customer service experience preferably in a healthcare-related or social services setting, or a combination of experience.
Knowledge of medical billing procedures, CPT and ICD-9 coding, and medical terminology.
Proficiency in data entry and Microsoft Office products.
Organizational skills, attention to detail, and follow-through.
Good written, verbal, and interpersonal communication skills, including the ability to communicate effectively with internal and external customers.
Ability to work collaboratively.
Flexibility to work additional hours as needed.
Examples of demonstrating Nova’s Core 4: Act with Passion, Work Together, Be Accountable, and Build Trust.

Nice To Haves

Medical office assistant certificate and/or college degree.
Customer service experience in a healthcare-related or social services setting.

Responsibilities

Adjudicate facility, professional, member-submitted, pharmacy, and dental claims according to established policies and procedures, including in- and out-of-network benefits.
Review vouchers and explanations of payments to identify and resolve claim-related issues.
Meet department performance measures for production, accuracy, policy and procedure knowledge, and timeliness.
Analyze, identify, and research edits involving policy inconsistencies, payment issues, and coding issues.
Maintain current knowledge of contracts, summary plan descriptions, and benefits.
Meet departmental deadlines and turnaround times and comply with state and federal regulations.
Use critical thinking to process claims.
Navigate systems and applications to locate information for claim scenarios.
Locate, read, interpret, and apply appropriate resources to claim scenarios.
Identify and communicate process opportunities or improvements.
Prioritize and manage claim-processing workload efficiently.
Communicate effectively with other departments within Independent Health to resolve claims-payment problems.
Respond to client, member, and provider inquiries about claim status, benefit designs, and claim payments in coordination with Customer Service Representatives.