Claims Adjudicator III

CareSource; Dayton (OH); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization seeks a Claims Adjudicator III responsible for processing various claims and acting as a technical resource for the claims team. This role requires strong knowledge of medical terminology, coding, and a minimum of three years experience in health insurance claim adjudication, offering a competitive hourly wage and a comprehensive benefits package.

Benefits

Comprehensive total rewards package

Flexible training schedules

Qualifications

• Minimum of three years of health insurance claim adjudication experience.
• Medicaid managed care claim adjudication experience preferred.
• One year recent CareSource Claim Adjudication experience preferred.

Responsibilities

• Process a wide variety of claims within department standards.
• Research and resolve claims with error messages.
• Act as a technical resource for the claims team.

Skills

Medical terminology

CPT-4 coding

ICD-10 coding

Attention to detail

Decision making

Problem solving

Customer service

Education

High School Diploma or equivalent

Post-secondary coursework in Healthcare

Tools

Excel

Word

Outlook

Job description

Job Summary:

The Claims Adjudicator III is responsible for processing a wide variety of claims within department standards and act as a technical resource to all Claims team associates.

Essential Functions:

• Process a wide variety of claims (at all pend levels) within department standards
• Research and resolve claims with “error messages” by researching and correcting codes, units, etc.
• Constructively interact with other departments such as Enrollment, Medical Management, Provider Operations, and Configuration to facilitate claim processing
• Recognize claims for possible fraud, waste, or abuse
• Process exception claims within timely filing limits
• Act as a technical resource to all Claims team associates by reviewing claims, training, providing job shadowing and answering questions
• Identify potential process improvements and participate and/or facilitate related initiatives
• Professionally and competently serve as Subject Matter Expert on claims processing both internally within Claims Department and other CareSource departments and externally as needed (regulators, auditors, etc.)

• Perform any other job duties as requested

Education and Experience:

• High School Diploma or equivalent required
• Post-secondary academic coursework, degree, or certification in Healthcare related field is preferred
• Minimum of three (3) years of health insurance claim adjudication experience is required
• Medicaid managed care claim adjudication experience is preferred
• One (1) year recent CareSource Claim Adjudication experience is preferred

Competencies, Knowledge and Skills:

• Intermediate computer skills such as Excel, Word and Outlook
• Medical terminology; CPT-4 and ICD-10 coding knowledge required
• Written and oral communication skills
• Ability to work independently and in a team environment
• Attention to detail
• Ability to remain focused in a production environment
• Proven knowledge of multiple products and reimbursement methodologies
• Knowledge of Medicaid
• Critical Listening and Thinking Skills
• Training/teaching skills
• Time management skills
• Customer service oriented
• Decision making/problem solving
• Leadership skills

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Flexibility to meet training schedules within standard scheduled hours
• Some weekends may be required based on business needs

Compensation Range:
$40,400.00 - $64,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Hourly

Competencies:
- Create an Inclusive Environment- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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