Medical Claims Adjuster I

About the role

This position plays a critical role in PEHP’s efforts to serve and create value for our members by processing a variety of medical claims proficiently and timely. The position includes a variety of professional duties related to processing claims. Successful performance for this position requires an attention to detail, the ability to learn complex claims processes while managing multiple diverse tasks, and a high level of commitment and dependability.

Responsibilities

• Receives and enters medical and/or Medicare claims for payment under medical and/or Medicare Supplement plans.
• Reviews claims for accuracy and completeness, verifies coverage and eligibility of patient.
• Adjudicates routine and complex claims according to established policy guidelines.
• Processes coordination of benefits on Medical and Dental claims.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality.
• Performs other related duties as required.

Requirements

• High School diploma and one (1) year of work experience.
• Specific experience in claims processing, and various administrative functions is preferred, or an equivalent combination of education and experience.

Knowledge, Skills, and Abilities

• Working knowledge of intricacies related to medical, dental, pharmacy, and Medicare Supplement claims.
• Knowledge of procedures and processes; intricacies related to medical, mental health and chiropractic claims.
• Familiarity with CPT, ICD-10-CM and HCPC’s coding and medical terminology.
• Experience with various office management systems related to alpha and numeric record keeping.
• Proficiency in personal computer operations and various program applications.
• Some knowledge of 10-key operation and mathematical skills.
• Excellent communication skills, including interpersonal communication and telephone etiquette.
• Ability to analyze a variety of routine claims management issues and problems and make routine corrections.
• Strong attention to detail.
• Ability to follow written and verbal instructions, prioritize work, multi-task, follow through with assignments, and perform within deadlines.
• Ability to deal effectively with stress caused by workload and time deadlines.
• Ability to work well in a team environment as well as independently.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.