Claims Adjudication Associate

Triwill Group; Charlotte (NC); Hybrid; USD 82,000 - 103,000; Full time

Job summary

Judi Health in Charlotte, NC is seeking a self-driven Claims Adjudication Associate to support the medical claims adjudication workflow on our enterprise health platform. In year one you will train on the JUDI Medical adjudication system and manage the operational adjudication process, escalations, subrogation, and stop-loss flows, while meeting standard SLAs.

In year two you will service new and existing clients, deepen understanding of JUDI capabilities, and engage internal and external

Qualifications

• Bachelor's degree strongly preferred.
• Experience managing a team of direct reports.
• 1+ years in health plan, claims adjudication, or TPA.
• Understanding of COB, adjustments, appeals, and inquiries.
• Excellent communication and project/time management skills.
• Patient advocacy and privacy protection knowledge.

Responsibilities

• Review and decide on medical claims submitted by networks or claimants.
• Support Customer Care with claims and benefits questions.
• Apply laws, regulations, and policy provisions to determine outcomes.
• Adjudicate claims via 837 EDI, HIPAA 1500, UB-04, or superbill.
• Meet standard SLA targets for claims processed per day.
• Assist in mail workflows for appeals, subrogation, and stop-loss.
• Build trusting client relationships through exceptional service.
• Communicate implementation guidance for adjudication infrastructure.

Skills

Time management

Communication

Customer service

Team leadership

Cross-functional collaboration

Education

Bachelor's degree

Tools

Jira

Miro

Confluence

Github

AWS Redshift

Job description

About Judi Health

Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.
At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health.

Location: Hybrid 3 days in Charlotte office

Position Summary:

Judi Health is seeking a self-driven Claims Adjudication Associate to support the Medical claims adjudication workflow for JUDI Health, our enterprise health platform.

In year one, this individual will train on the JUDI Medical adjudication system. This individual will be responsible for maintaining the operational adjudication process, member, and provider escalated inquiry management, subrogation, stop-loss, recoupment and adjustment flows, and adhering to standard and contractual claims processing SLAs.

In year two, this individual will be responsible for managing and servicing new and existing clients of JUDI’s Medical Claims Adjudication platform. This individual will be expected to maintain an in-depth understanding of the evolving capabilities of JUDI and our medical network support and client base. Exceptional communication skills and attention to detail are critical for communicating with internal and external stakeholders to build holistic support for medical claims processing.

Position Responsibilities:

• Review, assess, and make decisions on medical claims submitted by networks, claimants, or other parties.

• Provide support to Customer Care representatives in relation to claims and benefits questions from Members and Providers.

• The Claims Adjudicator reviews the facts of each case and applies the applicable laws, regulations, and policy provisions to determine the appropriate claim outcome.

• The Claims Adjudicator must be knowledgeable of the claims process, laws, and policies, as well as possess excellent communication skills and a commitment to providing outstanding customer service.

• Manually adjudicate claims received via 837 EDI file, HIPAA 1500 or UB-04 forms, or direct member reimbursement submissions via superbill submission.

• Adhere to standard SLA’s regarding number or percentage of claims processed per day

• Assist in management of claims related mail workflows including Appeals, subrogation, payments, and stop-loss.

• Build and maintain trusting relationships with clients through superior customer service.

• Assist in communications throughout the implementation process, including detailed and strategic guidance for adjudication infrastructure, processing, reporting, inquiry management, and complex claim situations/requests.

• Proactively identify execution risks and mitigation strategies.

• Identify and drive efficiencies to automate adjudication flows and reduce risk.

• Certain times of year may require meeting participation, service support or other requirements outside of standard business hours, including weekends.

• Responsible for adherence to the Judi Health Code of Conduct including reporting of noncompliance.

Minimum Qualifications:

• Bachelors degree strongly preferred

• Experience managing a team of direct reports

• 1+ years of work experience at a health plan, claims adjudicator, or TPA

• Well-versed in Benefit determinations

• Well-versed in impact of claims processing and adjudication in regards to COB, Adjustments, Appeals, and member/provider inquiries

• Act as a patient advocate, protecting privacy and confidentiality issues.

• Track record of leading cross-functional initiatives, driving high performance, meeting deadlines, and executing on deliverables

• Exceptional project / time management, prioritization, and organizational skills to ensure customer satisfaction

• Ability to shift between competing priorities and meet organizational goals

• Proficient in Microsoft office Suite and willing to adapt to software such as Jira, Miro, Confluence, Github, and AWS Redshift

• Excellent verbal, written, interpersonal and presentation skills

• Ability to work effectively with virtual teams

Preferred Qualifications:

• Medicare/Medicaid experience preferred

Charlotte, NC Salary Range

$82,400 — $103,000 USD

All employees are responsible for adherence to the Judi Health Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy.