Claims Adjudicator II

UNITE HERE HEALTH; Oak Brook (IL); On-site; USD 28,000 - 34,000; Full time

Benefits offered by this job

Medical

Dental

Vision

PTO

Holidays

401(k)

Pension

Short-Term Disability

Long-Term Disability

Life Insurance

AD&D

Flexible Spending Accounts

Commuter Transit

Tuition Assistance

Employee Assistance Program

Job summary

UNITE HERE HEALTH seeks a Claims Adjudicator II to review and adjudicate medical, disability, vision and dental claims, ensuring eligibility and accurate payment liability. The role requires interpretation of SPD/Plan Documents and accurate coding across multiple systems.

The position offers a 37.5-hour week, with fully remote work after one week of onsite training in Oak Brook, IL. Fluency in Spanish is preferred; benefits include medical, dental, vision, and retirement programs.

Qualifications

• 3–5 years of direct experience in medical claim adjudication.
• Knowledge of interpretation of benefit plans, limitations, exclusions, and SPD/Plan Documents.
• Experience with eligibility verification, medical coding, COB, subrogation and related processes.
• Experience with ICD-10 and CPT coding.
• Spanish fluency, spoken and written, preferred.

Responsibilities

• Screens claims for completeness of information.
• Verifies participant and dependent eligibility.
• Interprets plan benefits from SPD/Plan Documents.
• Codes basic information and determines payment liability.
• Evaluates diagnoses, procedures, and services for benefit compliance.
• Requests additional information from participants, employers, providers and other carriers.
• Handles MSP files and processes PIP claims.
• Adjudicates claims to meet productivity and quality goals.

Skills

Medical claim adjudication

Benefit interpretation

Eligibility verification

ICD-10 & CPT coding

Spanish language

Job description

UNITE HERE HEALTH serves 200,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The Claims Adjudicator II position will receive, examine, verify and input submitted medical claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries.

Essential Job Functions And Duties

• Screens claims for completeness of necessary information
• Verifies participant/dependent eligibility
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
• Codes basic information and selects codes to determine payment liability amount
• Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
• Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
• Handles the end to end process of Medicare Secondary Payer (MSP) files
• Processes Personal Injury Protection (PIP) claims
• Requests overpayment refunds, maintains corresponding files and performs follow-up actions
• Handles verbal and written inquiries received from internal and external customers
• Processes Short Term Disability claims
• Adjudicates claims according to established productivity and quality goals
• Achieve individual established goals in order to meet or exceed departmental metrics

Essential Qualifications

• 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment
• Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation and it’s related processes
• Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes
• Fluency (speak and write) in Spanish, preferred

Salary range for this position : Hourly $20.36 - $24.97. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) Fully Remote, after 1-week training onsite in Oak Brook, IL. (Travel and Lodging paid for by UHH)

We reward great work with great benefits, including but not limited to:

• Medical
• Dental
• Vision
• Paid Time-Off (PTO)
• Paid Holidays
• 401(k)
• Pension
• Short- & Long-term Disability
• Life
• AD&D
• Flexible Spending Accounts (healthcare & dependent care)
• Commuter Transit
• Tuition Assistance
• Employee Assistance Program (EAP)