Claims Examiner - Jefferson Health Plan
About The Position
Working under general supervision, the Claim Examiner adjudicates medical claims, in accordance with Health Partners' policies and procedures. This role involves reviewing pended claims, ensuring all appropriate documentation is completed before adjudication, and accurately completing service forms for pended claims. The Claims Examiner will also review audit results weekly, correcting errors in the claims processing system within designated timeframes, and follow established procedures for claims processing and high dollar claim review. Maintaining minimum performance standards for claim production and accuracy, and staying current with Claims Department policies and procedures are key aspects of this position. The role also includes assisting the unit in meeting and maintaining performance standards.
Requirements
- High School Diploma/GED
- Ability to maintain strict confidentiality of patient information obtained in the performance of job function
- Excellent communication skills required-both oral and written
- Basic understanding of computer applications
- General understanding of the principles of Managed Care
Nice To Haves
- 2 years claims processing experience or provider billing experience
Responsibilities
- Able to work in a constant state of alertness and safe manner
- Accurately adjudicates claims in compliance with data entry rules, On Line Processing Rules and contractual agreements.
- Reviews pended claims on a daily basis, assuring that all appropriate documentation is completed before adjudication.
- Accurately completes service forms for pended claims and routes to designated areas for resolution.
- Reviews audit results on a weekly basis, correcting errors in the claims processing system within designated timeframes.
- Follow established procedures and guidelines for claims processing and high dollar claim review.
- Maintains minimum performance standards as specified by departmental policies, such as claim production and accuracy.
- Keeps current with Claims Department policies and procedures.
- Assist the unit in meeting and maintain performance standards.
Benefits
- medical (including prescription)
- supplemental insurance
- dental
- vision
- life and AD&D insurance
- short- and long-term disability
- flexible spending accounts
- retirement plans
- tuition assistance
- voluntary benefits
- tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
