Job Description

Job Description

Job Description

We are hiring for a Claims Adjuster to join the team! The Claims Adjuster analyzes and processes requests and inquiries for adjustments to medical insurance claims in an accurate and timely manner while adhering to claims processing standards and Service Level Agreements. This position must be able to adequately communicate findings and be able to assist with escalated issues, and special projects.

Responsibilities:

• Performs retrospective claim adjustment reviewed as requested by Care First, FEP and/or Customer Service.
• Understanding and familiarity with Care First’s SalesForce application and appropriate messaging
• Federal Employee Program (FEP)
• Communicate claim adjustment analyses results to Care First and/or FEP or internal departments.
• Reporting error trends that are detected for future educational training purposes.
• Maintaining required departmental production and quality standards.
• Keep Manager advised of status of workload and identify problems for which help is needed.
• Follow regulations and company rules and policies as outlined in the Employee Handbook.
• Other duties as assigned.

Requirements:

• High school diploma or equivalent required. Some college/degree a plus.
• Minimum - three years of experience in the health insurance industry examining and adjudicating medical claims preferably with exposure to stating plan features and benefits and helping to resolve claims related issues.
• Familiarity with insurance products and insurance terminology, including CPT and ICD-9 coding. Coding Certificate desired for FEP (CPC, CCS).
• Ability to use automated claims adjudication software.
• Excellent verbal and written communication skills and ability to effectively deal with customer complaints and concerns.
• Work organization, problem solving, and basic math skills.
• Ability to make decisions and support them with documentation.
• Knowledge of, and the ability to learn: Microsoft Office Products, Internal software systems, the internet and overall familiarity with personal computers is required, as well as the ability to work with dual computer monitors preferred.
• Salesforce experience a plus.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Working Conditions:

• Flexibility to work in an office and/or at-home, remote office environment.
• Overtime and/or schedule flexibility are occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
• Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.

Competitive base pay starting at $48,317 annually.

This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.

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