Claims Processor, Advanced
About The Position
The Claims Processor, Advanced works on the Accumulations Team, which manages and maintains member accumulations by researching, auditing, updating, and posting data to ensure accurate deductible and out-of-pocket balances. The role monitors inventory, tracks aging, prioritizes audit requests, and processes member accumulation transfers between plans according to system guidelines. The team member also collaborates with business partners, supports audits and remediation, assists with training, and serves as a subject matter expert for testing and documentation reviews. This position reports to the Claims Operations Supervisor. The role independently processes complex and high-risk claims across multiple products or specialties, researches accumulations, produces reports, and identifies and resolves processing or system errors. It also supports workflow and documentation, provides guidance to peers, and may act as backup to lead roles. The position follows a hybrid workplace model, generally requiring in-office work two days each week for most teams. Employees living more than 50 miles from an office will work with their manager to determine in-office time based on business needs.
Requirements
- High school diploma or GED, or one year of additional relevant experience in lieu of a diploma.
- Five years of previous experience.
- Broad knowledge of operational systems and practices within Claims Processing.
- Proficiency in front- and back-end processing, including identifying, analyzing, and resolving errors.
- Demonstrated ability to process multiple claim types or specialties.
- Deep understanding of end-to-end claims processing fundamentals.
- Intermediate-to-advanced skills creating documents and files using Excel, Outlook, PowerPoint, and Word.
- Ability to work independently and in a team environment.
- Strong time-management skills and detailed research skills.
Responsibilities
- Research accumulations and update them accordingly.
- Independently process complex and high-risk claims across multiple products or specialties.
- Pull, format, and send reporting to necessary teams.
- Review applications and recommend system edits or changes as needed.
- Complete special processing assignments and coordinate with other departments to resolve issues when needed.
- Consistently exceed performance metrics and quality standards.
- Manage time effectively, multitask, conduct detailed research, meet deadlines, and maintain excellent quality.
- Serve as a subject matter resource for selected claim types and provide guidance to peers.
- Identify, analyze, and resolve system and processing errors with minimal escalation.
- Assist with training, documentation review, and workflow support; act as backup to lead roles.
- Perform other duties as assigned.
- Monitor inventory, track aging, prioritize audit requests, and process member accumulation transfers between plans according to system guidelines.
- Collaborate with business partners and assist with audits and remediation efforts.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
