Claims Adjudicator

Independent Health Association•Buffalo, NY

18d•Hybrid

About The Position

The Claims Adjudicator adjudicates and adjusts medical and/or dental claims against established criteria and in accordance with client Summary Plan Descriptions (SPDs), maintaining accuracy and productivity goals. The role responds to client, member, and provider inquiries about claim status, benefit designs, and claim payments, working with Customer Service Representatives. This is a hybrid position requiring onsite attendance at the Williamsville location. Compensation is $19.00 per hour; associates may also be eligible for a scorecard incentive, benefits, and paid time off. Immigration or work visa sponsorship is not provided.

Requirements

High school diploma required.
Six months of medical claims processing or medical billing experience and 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.
Strong 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 displaying 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 payment 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 and navigate systems and applications to locate claim-specific information.
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 in writing and verbally with other departments to resolve claims-payment problems.
Respond to client, member, and provider inquiries about claim status, benefit designs, and claim payments in conjunction with Customer Service Representatives.