Claims Processor II (Remote)

CareFirst•Baltimore, MD

2d•Remote

About The Position

Under general supervision, the Claims Processor II reviews and adjudicates paper and electronic claims, determining appropriate handling in accordance with organizational policies and procedures. The role examines and resolves non-adjudicated claims, identifies processing requirements based on contracts and policies, and processes product- or system-specific claims to support timely and accurate payments. This includes calculating deductibles and maximums and researching and resolving pending claims. The Claims Processor uses automated systems to route pending claims and ensure accurate completion according to medical policy, contracts, and organizational procedures. The role researches procedures extensively and may use training materials, emails, and medical policies to process claims correctly. The employee consults the quality team about unclear procedures or difficult claims and receives coaching from leadership, while completing ongoing developmental training. The position requires daily completion of productivity data used by leadership for performance reporting, scheduling, quality improvement, workflow design, and financial planning. The Claims Processor also supports Customer Service Representatives by providing feedback, resolving issues, and answering basic processing questions. The associate is primarily seated, with occasional walking or standing, regular use of hands for writing and computer or control operation, frequent talking and hearing, and occasional lifting of up to 25 pounds. Applicants must be eligible to work in the United States without sponsorship.

Requirements

High school diploma or GED.
Three years of claims experience required.
Demonstrated written and verbal communication skills.
Demonstrated strong analytical skills.
Demonstrated knowledge and understanding of claims systems and processes.
Demonstrated reading comprehension of materials used to adjudicate claims.
Ability to meet established deadlines and handle multiple internal and external customer-service demands within service expectations.
Ability to communicate effectively and provide positive customer service, including to demanding or challenging customers.
Must be eligible to work in the United States without sponsorship.

Nice To Haves

Three years of claims processing, billing, or medical terminology experience.

Responsibilities

Review and adjudicate paper and electronic claims in accordance with organizational policies and procedures.
Examine and resolve non-adjudicated claims and identify processing requirements based on contracts, policies, and procedures.
Process product- or system-specific claims to support timely payments; calculate deductibles and maximums and research and resolve pending claims.
Use automated system processes to route pending claims and ensure accurate completion according to medical policy, contracts, and organizational procedures.
Research procedures and apply training materials, emails, and medical policies as needed to process claims correctly.
Consult the quality team regarding unclear procedures or difficult claims and receive coaching from leadership.
Participate in ongoing developmental training to perform daily functions.
Complete daily productivity data used by leadership for performance statistics and operational planning.
Assist Customer Service Representatives by providing feedback, resolving issues, and answering basic processing questions.