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JOB DESCRIPTION
- Process, adjust or update various moderate to complex claims payments and payment errors for any business segment and/or claims-provider type
- Respond promptly and accurately to inquiries from Customer Service Professionals, subscribers, providers, physicians and other insurance carriers regarding claims payments.
- Meet or exceed established quality and performance standards
- Determine suspended claim resolution methods by reviewing benefit eligibility, claims history and other information
- Escalate claims requiring specialized resolution to subject matter experts based on department policies and guidelines to ensure the resolution
- Understand business requirement for the customer and provider segments with tailored solutions to their needs
- Identify system issues by documenting the issue, recommend potential solution and refer appropriate technical staff
- Work with designated Provider Services specialists to deliver services tailored to the provider services
- Review claims for possible “fraud and abuse” and send to Special Investigations Unit for additional investigation
- Use continuous improvement and knowledge of claims to drive efficiency and production gains; share best practices
- Coordinate with other insurance carriers and Medicare to determine payment liability
- Represent Claims interests on divisional or enterprise project teams
Hiring Requirements
* High school diploma or GED
* 3+ years of experience in related field.
A101142RDU_1778099908