Job Description

Job Description

Job Description

Claims Adjuster II

Are you an experienced professional in medical claims? We invite you to leverage your expertise and join our dedicated team as a Claims Adjuster II!

Job Summary:

As a Claims Adjuster II, you will play a critical role in analyzing claims to determine insurance carrier liability and interpreting contract benefits according to specific claims processing guidelines. Your daily responsibilities will involve organizing and utilizing information regarding benefits, contract coverage, and policy decisions. You'll coordinate workflow to align with check cycle days, ensuring all service guarantees are met. You'll maintain professional and positive relationships with policyholders, service providers, agents, attorneys, and other carriers, as well as with your peers and management.

Essential Duties & Responsibilities:

• Adjudication & Decision Making: Examine, perform, research, and make informed decisions to properly adjudicate claims and respond to written inquiries.
• Contract Interpretation: Accurately interpret contract benefits in line with claims processing guidelines.
• Strategic Understanding: Link the broad strategic concepts of our business to the day-to-day functions of claims processing.
• Comprehensive Claim Handling: Handle a wide variety of claim types within the department beyond the initial training.
• Professional Interaction: Maintain minimal but effective external contact with providers, agents, and policyholders.

Qualifications:

• Communication Skills: Excellent oral and written communication skills.
• Technical Proficiency: Proficient in PC applications with accurate typing skills (30 wpm).
• Relevant Experience: Previous experience in health, Medicare, or prescription claims adjudication is a plus.
• Organizational Skills: Strong organizational and decision-making skills.
• Team Collaboration: Team-oriented with a strong work ethic and reliability.
• Claims Expertise: Experience with UB/institutional (CMS-1450) and HCFA/professional (CMS-1500) claims.
• Medical Knowledge: Familiarity with medical terminology, procedure, and diagnosis codes preferred.
• Software Familiarity: Experience with Qiclink software is advantageous.
• Analytical Ability: Ability to calculate figures and co-insurance amounts.
• EOB Interpretation: Proficient in reading and interpreting Explanation of Benefits (EOBs).
• Adaptability: Capable of multitasking, prioritizing, problem-solving, and adapting to a fast-paced, dynamic environment.
• Independent Work: Ability to work independently while meeting quality and production standards.
• Policy Understanding: Clear understanding of policy benefits and procedures within the Claims unit.
• Integrity: Honesty and respect for company policies and procedures are essential.

Education & Experience:

• Educational Background: High School diploma or GED equivalent.
• Work Experience: Minimum of one year of related experience required.
• Industry Experience: Experience in medical/insurance is preferred, with Medicare Supplement experience being highly desirable.

If you are a dedicated professional with a passion for medical claims and a commitment to excellence, we want to hear from you! Apply today to become a valuable member of our Claims Adjuster team.

#talrooprofesional

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