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Claims Adjudicator
Independent Health. Adjudicate and adjust medical and/or dental claims against established criteria and specific client SPDs .
About the role
Key responsibilities & impact- Adjudicate and adjust medical and/or dental claims against established criteria and specific client SPDs
- Respond to client, member, and provider inquiries about claim status, benefit designs, and claim payments in conjunction with Customer Service Representatives
- Adjudicate facility, professional, member-submitted, pharmacy, and dental claim edits for in-network and out-of-network benefits
- Review vouchers and explanations of payments to identify and resolve claims-related issues
- Meet department performance measures for production, accuracy, policy and procedure knowledge, and timeliness
- Analyze, identify, and research policy, payment, and coding issues
- Maintain current contract, summary plan description, and benefit knowledge
- Adhere to departmental deadlines, turnaround times, and state and federal regulations
- Use critical thinking to process claims
- Navigate systems and applications to locate claim-specific information
- Locate, interpret, and apply appropriate resources to claim scenarios
- Identify and communicate process improvement opportunities
- Prioritize and manage claim-processing workload efficiently
- Collaborate with other Independent Health departments to resolve claims payment problems
Requirements
What you’ll need- High school diploma required
- Medical office assistant certificate and/or college degree preferred
- Six (6) months of medical claims processing or medical billing experience, or customer service experience preferably in a healthcare-related or social services setting; combination of experience accepted
- Knowledge of medical billing procedures
- Knowledge of CPT and ICD-9 coding
- Knowledge of medical terminology
- Proficiency with data entry and Microsoft Office products
- Solid organizational skills with attention to detail and follow-through
- Good written, verbal, and interpersonal communication skills
- Ability to communicate effectively with internal and external customers
- Ability to work collaboratively
- Flexibility to work additional hours as needed
- Ability to demonstrate Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust
- Must be able to work onsite at the Williamsville location as required for this hybrid position
- Immigration or work visa sponsorship will not be provided
Benefits
Comp & perks- First-class perks and benefits
- Culture that fosters growth, innovation and collaboration
- Scorecard incentive eligibility
- Full range of benefits
- Generous paid time off
- Professional growth and career development opportunities