Claim Processor job description

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Insurance Services and Placement - Claim Processor Job Description

Title: Claims Processor

FLSA Status : Non-Exempt

Reports to: VP, Insurance Services and Placement

Job Summary:

The Claims Processor is responsible for claims processing of new and existing claims and all correspondence related to claims.

Essential Functions:


Complete timely review and entry of new losses. Determine if coverage is in place and send documentation to insurance carriers. Follow up with carriers to ensure proper documentation of acknowledgements, determinations and final settlements. Review all determinations and discuss with carrier adjustors or TPAs. Maintain SOPs for all claims processes. Applies understanding of insurance policies and policy interpretation in order to assist clients and carriers with claim settlement Assist Account Service Managers, Producers, and Clients with claims questions or issues. Escalate complex claim questions to VP Insurance Services and Placement Complete claims reporting to Account Service Managers, Producers, Clients and Loan Protector Leadership.



Education and/or Experience:


Prior claim or agency processing a plus. High School diploma required. Associate or Bachelor degree preferred.



Knowledge, Skills and Competencies:


Strong written and oral communication skills Experience with Insurance Agency Management System (Applied or AMS). Experience with Microsoft Office Suite Excellent time management skills. Detail oriented Technical learning with strong desire to learn and acquire new skills. Ability to adapt to a changing environment and handle multiple priorities to meet deadlines.



Work Environment:


This job operates in a professional office environment. This role routinely uses standard office equipment such as computers

We are an Equal Opportunity Employer. We take pride in the diversity of our team and seek diversity in our applicants.

We enjoy the important work we do every day on behalf of our members.

Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

Job Summary

Claims Processor II is responsible for the investigation and resolution of all L&R leads generated from internal or external sources. Claims Processor II must demonstrate superior customer service skills because a majority of their time will be spent reviewing leads, contacting members, sales account managers, commercial insurers and employer group representatives. Excellent Verbal and written skills are required as the position involves extensive phone contact and recording appropriate order of benefit determination.

Job Description

Process Coordination of Benefit claims as assigned by supervisor:
Investigation of internal and external leads from all sources to determine if additional research is warranted.Initiate contact to internal and external sources to gather pertinent information regarding other coverage.Accurately record detailed information gathered in Health Rule Payer (HRP) and MACESSUnderstand and apply NAIC rules regarding the order of benefit determination for members with more than one health policy (including multiple THP policies) Comply with all department and/ or company guidelines in addition to all applicable laws and regulations including HIPAA.Creating COB records in HRPEnsure claim payment is updated to correctly reflect Tufts Health Plan's status as primary or secondary payer through the appropriate coordination of benefits Determine member's eligibility if in question.Check to determine if services rendered on the claim are allowable under the members benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.Manually calculate and/or apply pricing to each claim when necessary May assist partner departments by providing support on COB claims issues

Requirements

EDUCATION: Associates degree or equivalent business experience in a claims/customer service healthcare environment preferred.

EXPERIENCE: 24-48 months experience as a Point32Health Complex Claims Processor or similar claims processing or customer service experience required

SKILL REQUIREMENTS: Experience with Point32Health's internal applications, such as HRP, Macess, Medhok. Understanding of ACO, MCO plans, and a strong understanding of CPT, ICD-9 (ICD-10), HCPCS coding guidelines and CMS1500 & UB04 billing forms preferred. Position requires strong problem solving and analytical skills with the ability to multi-task. Must be able to work independently and as a part of a team. Advanced verbal and written skills to communicate internally and externally. Working knowledge of Microsoft Office applications and internet navigation is preferred.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: Overtime may be required during peak volume periods as requested by management. Requires ability to use personal computer, sitting for extended periods of time.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

On December 9, 2021, American Water announced the completion of the sale of its Homeowner Services Group (HOS) to funds advised by Apax , a leading global private equity advisory firm that invests in companies across four global sectors of Tech, Services, Healthcare and Internet/Consumer. In addition, HOS has a solid reputation with an A+ rating from the Better Business Bureau and American Water continues to provide HOS with Human Resources and job posting support for a period of time.

In joining Homeowner Services (HOS), you become part of a growing home warranty company with more than 450 dedicated employees who bring peace of mind to people across the country every day. Since 1992, we've provided homeowners with peace of mind and added financial stability through our home repair, maintenance and leasing plans, and we maintain a network of service professionals and technicians across multiple disciplines.
The Claims Examiner is responsible for the review, investigation, evaluation determining eligibility of claims created, and negotiating as necessary the resolution of claims that are in compliance with all policies and any state regulatory requirements. This role manages a large claim volume keeping adjudication at a high standard including but not limited to ensuring timely and accurate payments to service provider network and customers, and proactively assisting to improve process efficiencies by assisting with system enhancements of the claims management system that also support growth. This position is responsible for ensuring all Cost of Goods (COGS) are processed accurately and timely for financial accounting and leadership for month end.

Key Accountabilities:

Daily Responsibilities
Ensure customers and providers are paid timely and accurately within the terms and conditions of programs following best practices with ensuring compliance with state regulatory requirements.
Ability to communicate effectively with internal and external customers and keep challenging situations from escalating.
Responsible for handling incoming customer reimbursements requests from start to finish.
Validate daily NHS wire payment and exceptions.
Manage the reconciliation of Customer Preferred Pricing transactions.
Assist with inquiries regarding claim status and general product information with internal and external customers.
Analyze and validate a high level of claims data and entry into propriety operating system daily including daily audit and reconciliation of data and files.
Proactively address providers and team on provider non-adherence to contract coverage and terms.
Develop and build effective relationships within the department as well as with other departments including the contractors in our service provider network.

Claim Management Oversight
Understand database applications and operating systems to update SOP and job aids as appropriate for the department. Provides process improvement recommendations.
Subject matter expert on all claims processes to provide perspective to support business initiatives as well as system enhancements for Claims Management systems helping with testing to ensure optimal solutions by collaborating with core teams limiting risk to the business.
Understand the impact of other departments on claims management and how to identify, resolve situation identifying trends, discrepancies for areas of solutioning to rectify situations

Personal Accountabilities

Responsible for collaborating with teams effectively to drive operational excellence accomplishing department and business objectives. Complete performance goals in alignment with Company goals and objectives. Receptive to performance feedback and continuously seeks to improve own skills. Effectively maintain department workflow and personal productivity while performing job duties timely and accurately as well as additionally assigned.



Qualifications:


1 years experience in Accounting, A/P, Billing, A/R, or Claims. Strong decision making and analytical skills with the ability to enter at least 40 WPM. Detail orientated with strong organizational skills and the ability to adapt to changing priorities. Strong and effective verbal and written communication skills with the ability to influence others Self-starter, creative problem solver, persuasive and thorough, and strong team player Ability to deescalate customer or provider challenging situations without management. Ability to work with minimal supervision.



Education:
High School Diploma. Bachelor's degree in marketing, finance, business or related discipline preferred.


Work Environment:
The incumbent will be office based.


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American Water is firmly committed to Equal Employment Opportunity (EEO) and prohibits employment discrimination for employees and applicants
based on his or her age, race, color, pregnancy, gender, gender identity, sexual orientation, national origin, religion, marital status, citizenship, or because they are an individual with a disability, protected veteran or other status protected by federal, state, and local laws.