Senior Claims Processor

Highmark Health

21h•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.

Requirements

3 years of related experience
1 year of claims processing 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 thoroughly read guidelines ensuring claim accuracy and following directions.
Knowledge to research and handle complex claims.
Ability to assist with lead functions.
Ability to assist with questions from the claims processors/other teams.
High School Diploma/GED

Nice To Haves

Inquiry resolution system, OCWA, Oscar, Outlook experience
Knowledge to research and handle complex claims

Responsibilities

Receives and processes complex 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.
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.
Elevates issues to next level of supervision as appropriate and ensures a professional line of communication is maintained with internal and external customers.
Other duties as assigned or requested.