The Claims Processor will provide timely and accurate processing and adjudication of claims for a third party administrator. The role will research, and process claims for covered members across various products including medical, pharmacy, vision and related healthcare options.
- Work from a queue to review assigned claims at a set inventory level.
- Examine claims to identify key elements and processing requirements based on diagnosis, provider, medical policy, contract and/or policy.
- Efficiently and accurately analyze medical claims to determine whether or not the claim should be approved or denied for payment in accord with the plan / client conditions.
- Resolve pended healthcare claims and prior approval requests.
- Review and address provider inquiries regarding claim adjudication.
- Assist Customer Service Representative by providing feedback and resolving issues related to claims processing inquires.
- Meet performance and quality metrics.
- High School Diploma or equivalent.
- 2 years of medical claims processing including knowledge of medical terminology and working in a production environment.