Senior Claims Processor

Description:

This role will be located within the payment integrity department and work collaboratively with team members and department/ enterprise associates who support efforts to identify aberrant provider billing.

A Day In The Life

• Administers client specific contract benefits.
• Translate narrative descriptions into proper code.
• Research and resolve complex system edits.
• Ensure timely and accurate payment or denial of adjustments by monitoring reporting and following through with leadership or Claim Processors.
• Document any additional information or specific action taken using the proper system.
• Identify contract specific situations and manually calculate contract benefits using pricing and out-of-pocket procedures.
• Research and process or adjust high dollar claims.
• Analyze complex requests to determine how the original claim processed.
• Determine outcome of a reprocessed claim before the claim finalized. Identify and recommend areas for process improvement.
• Complete assigned special projects that require research, analysis and documentation.
• Serve on committees and task teams related to claims or adjustment efficiencies and methodologies.
• Provide on-the-job training and mentoring to Claim Processors and Associate Claim Processors.
• Research and respond to complex written correspondence via phone or in writing.

Nice To Have
 

• Ability to take direction and to navigate through multiple systems simultaneously.
• Knowledge of administrative and clerical procedures and systems such as Excel in order to manage workload.
• Ability to use mathematics to adjudicate claims.
• Ability to solve problems within pre-defined methods and guidelines.
• Knowledge of operating systems specific to claim processing.
• Oscar claim adjustment experience.