Claims investigator serp_jobs.h1.location_city

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management, meeting and / or exceeding member, plan sponsor, and provider expectations.

Position Summary / Mission

Reviews and adjudicates routine claims in accordance with claim processing guidelines.

Fundamental Components & Physical Requirements include but are not limited to :

• Analyzes and approves routine claims that cannot be auto adjudicated.
• Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
• Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
• Routes and triages complex claims to Senior Claim Benefits Specialist.
• Proofs claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.
• May facilitate training when considered a topic subject matter expert.
• Manages claims on desk, route / queues, and ECHS within specified turn-around-time parameters, in accordance with prescribed operational guidelines.
• Utilizes all applicable system functions ensuring accurate and timely claim processing, including Claim Check, reasonable and customary data, and other post-containment tools.

Performance Measures

Background / Experience Desired

Experience in a production environment.

Qualifications

Education and Certification Requirements

High School or GED equivalent.

Additional Information (situational competencies, skills, work location requirements, etc.)

Additional Information

All your information will be kept confidential according to EEO guidelines.

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