• Job Description

  Req#: 107286
  Employer Industry: Healthcare Services
  
  Why consider this job opportunity:
  - Opportunity for career advancement and growth within the organization
  - Supportive and collaborative work environment
  - Chance to make a positive impact on claims processing and member experience
  - Engage in departmental training and professional development activities
  - Work with a diverse range of claim payment systems and medical terminology
  
  What to Expect (Job Responsibilities):
  - Review claims for compliance with plan guidelines and approve or deny payment accordingly
  - Document claims adjudication decisions clearly in Claim Notes and consult reference materials for proper coding
  - Coordinate claims adjudication against individual enrollee eligibility, authorizations, and benefit verification
  - Proactively identify process improvements to reduce rework and ensure accurate payment
  - Maintain timely responses to appeals and reconsideration requests
  
  What is Required (Qualifications):
  - Minimum of 3-5 years of experience in claims adjudication, including knowledge of PPO, Medicaid, ERISA, Medicare, and various claim payment systems
  - Proficient in MS Access, Google Sheets, and Excel
  - Knowledge of medical terminology, ICD-10, CPT, and HCPCS coding
  - Excellent verbal and written communication skills for effective interaction with staff, members, and providers
  - Ability to calculate allowable amounts such as discounts, interest, and percentages
  
  How to Stand Out (Preferred Qualifications):
  - Experience processing claims on the HealthEdge System
  - Strong interpersonal and problem-solving skills
  - Familiarity with Windows operating systems
  - Ability to work in a team environment and manage competing priorities
  
  #HealthcareServices #ClaimsProcessing #CareerOpportunity #Teamwork #ProfessionalDevelopment
  
  We prioritize candidate privacy and champion equal-opportunity employment. Central to our mission is our partnership with companies that share this commitment. We aim to foster a fair, transparent, and secure hiring environment for all. If you encounter any employer not adhering to these principles, please bring it to our attention immediately.
  We are not the EOR (Employer of Record) for this position. Our role in this specific opportunity is to connect outstanding candidates with a top-tier employer.

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