PURPOSE
The purpose of this position is to support Claims and the automation of the high dollar claim review process. This role would be a liaison between the Claims Department and our networks and vendors, ensuring all information is received and reviewed within outlined timeframes for high-dollar claims that meet the defined criteria.
ESSENTIAL JOB FUNCTIONS AND DUTIES
- Coordinates with the Claims Support team once medical records are received from the networks
- Requests medical records from networks if they are not received timely
- Submits medical records and all pertinent information to Medical Management and/or Claim review vendors
- Tracks the status of all submitted cases to vendors to ensure timelines are met
- Follows up with vendors if claims are approaching the deadline
- Coordinates meetings with vendors and Medical Management as needed
- Adjudicates corrected claims according to the plan benefit designs
- Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation related to benefit requirements, the accuracy of the claim filed, and the appropriateness or frequency of care rendered
- Establishes and maintains relationships with key stakeholders to ensure the successful completion of high dollar claims under review.
- Offers suggestions on process improvement initiatives by identifying patterns and/or trends
- Generates and provides regular status reports of high-dollar claims, including trends, challenges, and outcomes to the Leadership team
- Assists with claims-related projects and reporting as needed
- Contributes ideas to plans and achieve department goals
- Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth
- Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
- Performs other duties as assigned within the scope of responsibilities and requirements of the job
- Performs Essential Job Functions and Duties with or without reasonable accommodation
ESSENTIAL QUALIFICATIONS
Years of Experience and Knowledge
- 4 ~ 6 years of related experience in a medical claim adjudication environment, or 3 years in a health care or insurance environment
- Working knowledge and experience interpreting benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
- Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
- Experience with medical terminology, International Classification of Diseases (ICD)10 and Current Procedures Terminology (CPT) codes
Education, Licenses, and Certifications
- Bachelor's degree in Health Care Administration or related field or equivalent work experience required
- Preferred: AAPC or AHIMA Certification
Skills and Abilities
- Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook)
- Intermediate level Microsoft Excel skills
- Exceptional communication skills (verbal and nonverbal)
- Excellent presentation skills
- Ability to work independently
- Proficient problem-solving skills
- 10% ~ 15% travel
Hourly range for this position: $24.61~$30.15. Actual hourly rate may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.
Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) with potential for hybrid work-from-home arrangement.
We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).
