Claims Processor l

ProCare Rx•Southfield, MI

12d•Onsite

About The Position

This role involves receiving, analyzing, and processing various types of claims (medical, dental, vision, FSA, or HRA) for assigned groups. The Claims Processor ensures accurate processing according to benefit plan design and regulations, evaluates underpayments, resolves non-payments and rejected claims, and follows through until claims are fully resolved and payments are issued. Responsibilities also include creating Explanation of Benefits or letters to providers, identifying and escalating claims for review or audit, and ensuring timely and accurate completion of required documentation. The position requires handling incoming calls regarding claim processing, provider support, and member benefit coverage, as well as making outgoing calls to gather additional information. Daily tasks include retrieving and sorting mail, faxes, and emails, and performing clerical functions such as data entry, filing, sorting, typing, organizing, and recording information. Additionally, the role may involve training co-workers and new employees, and performing various related duties as assigned.

Requirements

High school diploma or equivalent required.
Minimum two years of experience as a medical claims processor, medical biller or a similar service position in the health care industry.
Must be flexible with scheduled work hours.
Must have strong customer service orientation and excellent communication skills, and the ability to work effectively with clients, medical providers and plan members.
Proficient PC skills in Windows-based applications.
Ability to be flexible and quickly adapt to the changing needs in the department.
Must be highly organized with strong attention to detail.
Must be dependable and demonstrate responsible work patterns.
Must have a high level of professionalism and courtesy.

Nice To Haves

Post high school education preferred.

Responsibilities

Receive, analyze and process assigned claims by product (medical, dental, vision, FSA or HRA) and group, ensuring accurate processing based on benefit plan design and/or regulations.
Evaluate underpayments, resolve non-payments and rejected claims, and follow through until the claim is completely resolved and check is issued.
Create appropriate Explanation of Benefits or letter to provider for each claim.
Identify and escalate claims for review or audit based on business rules.
Ensure required documentation or reporting is completed timely and accurately.
Answer incoming telephone calls related to claim processing, provider support and member benefit coverage options.
Make outgoing calls to members and providers to obtain additional information as needed.
Retrieve and sort mail, fax and email to ensure timely and accurate handling and response.
Perform clerical functions including data entry, filing, and sorting, typing, organizing, and recording information.
Train co-workers and new employees, as required.
Perform various related duties as assigned.