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This position will report to the Claims Manager, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team will review and oversee the adjudication of claims ranging from the simple data entry to complex specialty claim research. The Claims Team will analyze and process insurance claims, checking for validity. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluate online entry, error correction, and quality control for final adjudication of paper/electronic claims.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School diploma/GED

EXPERIENCE:

1. One (1) year of experience working with medical or institutional claim data entry OR One (1) year of customer service experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate Degree in related healthcare field.

EXPERIENCE:

1. Two plus years of medical or institutional claims processing and customer service experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Determines accuracy and completions of claim information. Entry/verifies claims data.

2. Resolves claim edits, review history records, and determine benefit eligibility for service. 

3. Reviews payment levels to arrive at final payment determination.

4. Meets all production and quality standards, maintaining workques according to department standards.

5. Effectively communicates with internal and external staff.

6. Elevates issues to next level of supervision, as appropriate.

7. Ensures accuracy of data entered and record maintenance.

8. Attends all required training classes, demonstrating proficiency and ability to learn.

9. Other duties as deemed appropriate by the Claims Manager.  

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit for extended periods of time.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)

2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access) Internet Explorer and EPIC

SKILLS AND ABILITIES:

1. Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

2. Ability to take direction and to navigate through multiple systems simultaneously.

3. Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette

4. Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.

5. Ability to use mathematics to adjudicate claims

6. Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services.

7. Knowledge and understanding of medical terminology, third party payors and insurance preferred.

8. Requires attention to detail, the ability to be organized and to be able to perform multiple tasks simultaneously.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Day (United States of America)

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2902 PHH Claims Operations