Claims Adjudicator

Jobtailor; Buffalo (NY); On-site; USD 42,000 - 62,000; Full time

Job summary

Independent Health is seeking a claims adjudication specialist to review and process medical, facility, professional, member-submitted, pharmacy and dental claims. You will adjudicate based on policies, examine payments, and resolve related issues.

Required are a high school diploma (medical office certificate or college degree preferred) and at least 6 months of medical claims processing experience, with CPT/ICD-9 coding knowledge and proficiency in data entry and Microsoft Office.

Qualifications

• Six (6) months of medical claims processing/medical billing experience, customer service experience preferably in a healthcare related or social services setting; OR combination of experience.
• Knowledge of medical billing procedures; CPT and ICD-9 coding and medical terminology knowledge required.
• Proficiency with data entry skills and Microsoft Office products.

Responsibilities

• Adjudicate claims based on established policies and procedures for facility, professional, member submitted, pharmacy and dental claim edits.
• Review vouchers/explanation of payments to identify and resolve claims related issues.
• Continually meet department performance measures as it relates to production, accuracy, knowledge of policy and procedure and timeliness of claims adjudication.
• Analyze, identify and research, as needed, edits which demonstrate inconsistency in regard to policy, payment issues and coding issues.
• Maintain current contract, summary plan description and benefit knowledge.
• Ability to adhere to departmental deadlines and turn-around times, to be compliant with State and Federal regulations.
• Effectively utilize critical thinking skills to process claims.
• Efficiently navigate through systems and applications to locate information specific to claim scenarios.
• Accurately locate resources and read, interpret, and apply appropriate information to various claim scenarios.
• Identify and communicate process opportunities or improvements.
• Prioritize and manage claim processing workload in an efficient manner.
• Effective written, verbal and interpersonal communication with other departments within Independent Health to resolve problems related to claims payment.

Skills

Medical claims processing

CPT coding

ICD-9 coding

Data entry

Microsoft Office

Organizational skills

Communication

Collaboration

Critical thinking

Education

High school diploma

Medical office assistant certificate

College degree

Job description

Responsibilities

• Adjudicate claims based on established policies and procedures for facility, professional, member submitted, pharmacy and dental claim edits.
• Review vouchers/explanation of payments to identify and resolve claims related issues.
• Continually meet department performance measures as it relates to production, accuracy, knowledge of policy and procedure and timeliness of claims adjudication.
• Analyze, identify and research, as needed, edits which demonstrate inconsistency in regard to policy, payment issues and coding issues.
• Maintain current contract, summary plan description and benefit knowledge.
• Ability to adhere to departmental deadlines and turn-around times, to be compliant with State and Federal regulations.
• Effectively utilize critical thinking skills to process claims.
• Efficiently navigate through systems and applications to locate information specific to claim scenarios.
• Accurately locate resources and read, interpret, and apply appropriate information to various claim scenarios.
• Identify and communicate process opportunities or improvements.
• Prioritize and manage claim processing workload in an efficient manner.
• Effective written, verbal and interpersonal communication with other departments within Independent Health to resolve problems related to claims payment.

Requirements

• High school diploma required; medical office assistant certificate and/or college degree preferred.
• Six (6) months of medical claims processing/medical billing experience, customer service experience preferably in a healthcare related or social services setting; OR combination of experience.
• Knowledge of medical billing procedures; CPT and ICD-9 coding and medical terminology knowledge required.
• Proficiency with data entry skills and Microsoft Office products.
• Solid organizational skills with attention to detail and follow through.
• Good written, verbal and interpersonal communication skills.
• Demonstrated ability to effectively communicate with internal and external customers.
• Must be able to work collaboratively.
• Flexibility to work additional hours as needed.
• Proven examples of displaying Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust.

Core Competencies

Demonstrates expertise in medical claims processing, including knowledge of CPT and ICD-9 coding, while effectively communicating with internal and external customers. Exhibits strong organizational skills and critical thinking abilities to ensure compliance with policies and regulations.