Adjudicator, Provider Medical Claims (Inbound Calls)

About the Role

Responds to incoming calls from providers regarding claims inquiries, providing excellent customer service, support, and issue resolution. Documents all calls and interactions. Supports provider claims adjudication activities, including addressing claim issues, researching, investigating, and ensuring appropriate resolution of claims.

Responsibilities

• 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 member enrollment, provider information management, benefits configuration, and claims processing teams to appropriately address provider claim issues.
• Responds to incoming calls from providers regarding claims inquiries, providing excellent customer service, support, and issue resolution; documents all calls and interactions.
• 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 claim function efficiency.
• Completes basic claims projects as assigned.

Requirements

• 2 years of experience in a clerical role in a claim 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.
• Proficiency in Microsoft Office suite and applicable software programs.

Skills

• Salesforce
• QNXT
• Pega
• Claim Shark
• Cotiviti

Pay

Pay Range: $15.58 - $31.97 per hour. Actual compensation may vary based on geographic location, work experience, education, and/or skill level.