Claims Adjudicator III

About the role

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our Claims Adjudicator III position collaborates with the team Supervisor to provide direction and support to the team. This involves adjudicating complex medical, vision, dental, and short-term disability claims, as well as, escalated member and provider inquiries within established timeframes.

Responsibilities

• Successfully investigate and respond to escalated inquiries from internal and external sources
• Interacts with vendors and other UHH operational areas to resolve complex issues
• Analyzes problems, identifies and develops alternative solutions, and implements recommendations
• Triages claims and inquiries to determine if additional information or documentation from members, employers, providers and other insurance carriers is required
• Verifies participant/dependent eligibility utilizing multiple internal systems
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents to ensure accuracy
• Responsible for comprehensive research and end to end processing of Medicare Secondary Payer (MSP) files, Personal Injury Protection (PIP) claims, Short Term Disability claims, Subrogation files, and complex claim adjustments
• Requests overpayment refunds, maintains corresponding files and performs follow-up actions
• Handles verbal and written inquiries received from internal and external customers
• Identifies areas for process improvement and makes recommendations to management
• Collaborates with team Senior and Supervisor to lead individual and/or team training sessions
• Demonstrates necessary competence in technical, industry standard and soft skills to effectively support team
• Acts as a subject matter expert providing support and mentoring to peers
• Partners with other departmental areas on new and updated processes
• Adjudicates claims and complex inqiures according to established productivity and quality goals
• Achieve individual established goals in order to meet or exceed departmental metrics
• Contributes ideas to plans and achieving department goals

Qualifications

• 4 ~ 6 years of direct experience in a medical claim adjudication environment
• Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Working knowledge of plan design documents and pricing methodologies
• Working knowledge and experience in medical claims adjudication, preferably in a multi-employer environment
• Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA
• High School Diploma or GED, College degree preferred or equivalent work experience required
• Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook)
• Intermediate level Microsoft Excel skills
• Manage competing deadlines and multiple projects in a fast-paced environment
• Excellent communication skills (verbal and written)
• Exceptional time management, organizational and problem-solving skills
• Ability to demonstrate good judgment and have excellent critical thinking skills
• Ability to work independently with minimal supervision in a fast-paced environment

Benefits

• Medical
• Dental
• Vision
• Paid Time-Off (PTO)
• Paid Holidays
• 401(k)
• Short- & Long-term Disability
• Pension
• Life
• AD&D
• Flexible Spending Accounts (healthcare & dependent care)
• Commuter Transit
• Tuition Assistance
• Employee Assistance Program (EAP)