Adjudicator, Provider Claims-On The Phone (Remote)

Job Summary

Respond to inbound calls to provide support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating, and ensuring appropriate resolution of claims.

Essential Job Duties

• Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support, and issue resolution; documents all calls and interaction.
• Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas / provider billing to facilitate resolution.
• Collaborates with the member enrollment, provider information management, benefits configuration, and claims processing teams to appropriately address provider claim issues.
• Assists in reviews of state and federal complaints related to claims.
• Collaborates with other internal departments to determine appropriate resolution of claims issues.
• Researches claims tracers, adjustments, and resubmissions of claims.
• Adjudicates or readjudicates high volumes of claims in a timely manner.
• Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership.
• Meets claims department quality and production standards.
• Supports claims department initiatives to improve overall claims function efficiency.
• Completes basic claims projects as assigned.

Required Qualifications

At least 2 years of experience in a clerical role in a claims, and / or customer service setting, including experience in provider claims investigation / research / resolution / reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. Research and data analysis skills. Organizational skills and attention to detail. Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. Customer service experience. Effective verbal and written communication skills. Microsoft Office suite and applicable software programs proficiency.