Job Summary:

• The Claims Processor is responsible for reviewing and adjudicating both paper and electronic medical claims in accordance with organizational policies, medical guidelines, and contractual requirements.
• Under general supervision, the role involves evaluating claims for accuracy, determining payment eligibility, and ensuring timely and compliant processing through the use of internal systems and procedures.

Pay Range: $20 - $23 an hr.

Key Responsibilities:

Claims Adjudication & Resolution – 55%

• Review and resolve pending or non-adjudicated medical claims, ensuring compliance with applicable policies, medical guidelines, and contract terms.

• Use internal systems to process system-specific claims and ensure timely payments.

• Calculate deductibles, maximums, and perform accurate adjudication using automated workflows and multiple platforms.

Research & Quality Assurance – 25%

• Conduct in-depth research using policy documents, training materials, and internal communications to resolve complex claim issues.

• Consult with the quality team and leadership for guidance on unclear procedures.

• Participate in ongoing training and development to stay updated on system and policy changes.

Reporting & Productivity – 10%

• Accurately record daily productivity data used for performance tracking and organizational planning.

• Contribute to quality improvement and workflow optimization efforts through timely and precise documentation.

Team Support – 10%

• Provide support to Customer Service Representatives by clarifying claim status and resolving processing-related inquiries.

• Offer feedback and assistance on basic claims processes to internal stakeholders.

Qualifications:

Required:

• High School Diploma or GED

• Minimum of 3 years of claims processing experience

Preferred:

• 3+ years in medical claims processing, billing, or working with medical terminology

• Familiarity with FACETS Claims Processing System

Skills & Competencies:

• Strong attention to detail and organizational skills

• Knowledge of medical claims procedures and health insurance policies

• Ability to navigate and utilize multiple claims systems

• Effective written and verbal communication

• Problem-solving and analytical thinking

• Ability to work independently and collaboratively