Researches and adjudicates all types of claims to ensure that protocols are followed with regard to provider contracts, member benefit schedules, established guidelines, and departmental policies and procedures.
Essential Functions & Responsibilities
- Processes & adjudicates the claims for accounts requiring multiple disciples in claims processing.
- Verifies claim information.
- Reviews referral information for verification of services rendered.
- Reviews eligibility for verification of member eligibility at time of service.
- Enters claims information into the claims adjudication system – when applicable.
- Validates results of claims after completion of pre-processor, adjudication & claims pricing.
- Corrects all system edits as a result of the 3 step claims process.
- Researches, reviews and adjudicates pended claims.
- Recognizes claims issues/problems, refers them to management and/or appropriate party, and assists in the review and implementation of resolution.
- Assures that claims are processed in accordance to member benefits, provider contact terms, network protocols, medical authorization and departmental guidelines.
- Maintains individual productivity reports on claims adjudication.
- Maintains production and quality standards established by Claims Department Management.
- Provides back up to the clerical staff, other claims examiners and claims customer service.
- Some overtime may be required.
- Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
- Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
- Ability to come to work and work the regular schedule and shift for the position.
- Compliance with all personnel policies and procedures.
- Special projects and other duties as assigned by senior management.
- Perform additional duties and related essential duties as assigned.