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Claims Processor
Highmark Health. Screen, review, evaluate online entries, correct errors, and perform quality control review and final adjudication of paper/electronic claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims processing, including adjudication, error correction, and quality control, while effectively communicating with customers and maintaining accurate records. Proficient in navigating multiple systems and applying administrative procedures to ensure compliance with organizational policies.
Highest-signal resume keywords
Claims AdjudicationQuality Control ReviewData AnalysisVerbal And Written CommunicationProblem Solving
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingMathematics For Claims AdjudicationAdministrative ProceduresData EntryClaims AdjustmentBenefit DeterminationError CorrectionRecord ManagementSystem NavigationCritical Data Analysis
Soft Skills
Professional CommunicationAbility To Take Direction
Tools & Technologies
Operating Systems For Claim Processing
Certifications & Qualifications
High School Diploma/GED
Industry Keywords
Claims BillingClaims ReviewBenefit EligibilityQuality StandardsCustomer Interaction
About the role
Key responsibilities & impact- Screen, review, evaluate online entries, correct errors, and perform quality control review and final adjudication of paper/electronic claims
- Determine whether to return, deny, or pay claims according to organizational policies and procedures
- Review processed claims and inquiries to determine corrective action, including adjusting claims as necessary
- Use enrollment, benefit, and historical claim processing information to take corrective action
- Coordinate benefits and interact with customers as needed
- Complete claims adjustments accurately and timely in response to audits, member/provider calls, other insurance information, appeals, and system changes
- Provide technical assistance in researching and resolving inquiries
- Receive and process claims by entering and verifying claims data
- Resolve claim edits, review history records, determine benefit eligibility, and review payment levels for final payment determination
- Escalate issues appropriately while maintaining professional communication with internal and external customers
- Meet production and quality standards, maintain accurate records and timekeeping, and attend required training
Requirements
What you’ll need- High School Diploma/GED
- Strong verbal and written communication skills
- Ability to take direction and to navigate through multiple systems simultaneously
- Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records
- Ability to use mathematics to adjudicate claims
- Ability to solve problems within pre-defined methods and guidelines
- Knowledge of operating systems specific to claim processing
- Ability to review claims and analyze critical data
- Reading benefits, investigating edits and making benefit determinations as required in adjusting and adjudicating most types of claims
- 1 year claim billing or processing experience preferred