Claims Processor

Highmark Health • Washington, DC

2d • Onsite

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/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Reviews processed claims and inquiries to determine corrective action including adjusting claims as necessary and takes the corrective action steps using enrollment, benefit and historical claim processing information; may coordinate benefits and interact with customers. Responsible for the timely and accurate completion of claims adjustments which could be a result of internal/external audits, member/provider phone calls, other insurance information received, appeals, and system changes, etc.; provides technical assistance in researching and resolving inquiries. Due to Department of Defense (DOD) contract requirements, the incumbent who fills this position must be a US citizen, and must also pass a background check.

Requirements

• High School Diploma/GED
• 1 year of related experience
• Strong verbal and written communication skills.
• Ability to take direction and to navigate through multiple systems simultaneously.
• Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
• Ability to use mathematics to adjudicate claims.
• Ability to solve problems within pre-defined methods and guidelines.
• Knowledge of operating systems specific to claim processing.
• Ability to review claims and analyze critical data.
• Reading benefits, investigating edits and making benefit determinations as required in adjusting and adjudicating most types of claims.
• Researches and finalizes claims, adjustments, inquiries and reports as required.
• US citizen (due to DOD contract requirements)
• Must pass a background check (due to DOD contract requirements)

Nice To Haves

• 1 year of claims processing experience
• Inquiry resolution system, OCWA, Oscar, Outlook experience

Responsibilities

• Receives and processes claims to include entering/verifying claims data; determines if claim information is complete and correct.
• Resolves claim edits, reviews history records and determines benefit eligibility for service.
• Reviews payment levels to arrive at final payment determination.
• Elevates issues to next level of supervision as appropriate and ensures a professional line of communication is maintained with internal and external customers.
• Meets all production and quality standards, ensuring timeliness and accuracy of all work given by support staff/management.
• Maintains accurate records, including timekeeping records and attends all required training classes.
• Other duties as assigned or requested.

Benefits

• Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

What This Job Offers

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