Claims Processor

Highmark Health

2d • $19 - $24 • Remote

About The Position

This job is responsible for screening, reviewing, evaluating online entry, correcting errors, and/or performing quality control review and final adjudication of paper and electronic claims. The Claims Processor determines whether to return, deny, or pay claims in accordance with organizational policies and procedures. The role reviews processed claims and inquiries to identify corrective action, including adjusting claims as necessary, using enrollment, benefit, and historical claim processing information. The position may coordinate benefits and interact with customers. It is also responsible for timely and accurate completion of claims adjustments resulting from audits, member or provider calls, other insurance information, appeals, system changes, and other causes, and provides technical assistance in researching and resolving inquiries.

The role requires adherence to ethical and legal standards, company policies, and behavioral expectations. Employees may access confidential customer information and must protect it at all times, comply with HIPAA and company privacy and information security policies, and follow the company Code of Business Conduct and applicable laws and training requirements.

Requirements

• High School Diploma or GED.
• Strong verbal and written communication skills.
• Ability to take direction and navigate multiple systems simultaneously.
• Knowledge of administrative and clerical procedures and systems, including word processing and managing files and records.
• Ability to use mathematics to adjudicate claims.
• Ability to solve problems within predefined methods and guidelines.
• Knowledge of operating systems specific to claim processing.
• Ability to review claims and analyze critical data.
• Ability to read benefits, investigate edits, and make benefit determinations when adjusting and adjudicating most types of claims.
• Ability to research and finalize claims, adjustments, inquiries, and reports as required.

Nice To Haves

• One year of claim billing or processing experience.

Responsibilities

• Receive and process claims, including entering or verifying claims data and determining whether information is complete and correct.
• Resolve claim edits, review history records, determine benefit eligibility for services, and review payment levels to make final payment determinations.
• Escalate issues to the next level of supervision when appropriate and maintain professional communication with internal and external customers.
• Meet production and quality standards and ensure work is completed accurately and on time.
• Maintain accurate records, including timekeeping records, and attend required training classes.
• Review processed claims and inquiries to determine and carry out corrective actions, including claim adjustments.
• Research and resolve inquiries and provide technical assistance.
• Coordinate benefits and interact with customers as needed.
• Perform other duties as assigned or requested.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED