CLAIMS ADJUSTER (147)

The Loomis Company; Berkshire Heights (PA); On-site; USD 52,000 - 78,000; Full time

Job summary

The Loomis Company is seeking an attentive Claims Adjudicator to review and process medical claims in line with plan documentation. You will provide prompt service to claimants, providers, and clients by phone or correspondence, while achieving daily production goals and maintaining confidentiality of sensitive information.

Qualifications include a High School Diploma or GED with 1–3 years adjusting experience; strong detail orientation, analytical thinking, and excellent communication skills.

Qualifications

• High School Diploma or GED required with 1–3 years adjusting experience.
• Direct experience adjudicating medical claims is highly preferred.
• Strong attention to detail and accuracy in processing.

Responsibilities

• Examine, process, calculate and adjudicate claims per plan documentation.
• Maintain customer service logs within 5 days and HR logs within 2 days.
• Meet daily claim production goals and respond to inquiries via phone or mail.
• Keep claims information confidential and comply with HIPAA requirements.
• Attend continuing education on claims processing as needed.

Skills

Attention to detail

Analytical thinking

Problem solving

Verbal communication

Written communication

Time management

Microsoft Office

Claims system

Education

High School Diploma or GED

1-3 years adjusting experience

Tools

Microsoft Office

Claims System

Job description

SUMMARY:Adjudicates claims and provides service to clients, claimants, and providers. Meet or exceed defined processing production standards, processing accuracy standards and customer service accuracy standards.DUTIES AND RESPONSIBILITIES:Examine, process, calculate and adjudicate claims in compliance with plan documentation.Process any open audits daily.Follow daily direction to process high dollar claims and other priorities/issues listed on the daily reports that are distributed twice each day (morning and afternoon)Maintain customer service logs within a 5-day turnaround time.Maintain HR logs within a 2-day turnaround time.Comply with state laws, policy, company procedures, and plan documentation.Enter codes and verify data for computer processing.Meet or exceed daily claim production goals.Provide service to claimants, providers, and clients with problems or questions regarding their claims and/or policies via telephone or correspondence.Meet or exceed customer service quality standards.Protect operations by keeping claims information confidential.Attend continuing education on claims processing, as needed.Other functions may be assigned as business conditions change.Business conditions may require overtime, as needed.OTHER SKILLS AND ABILITIES:Strong attention to detail to carefully review documents and evolving policies.Analytical thinking skills to interpret an extensive variety of instructions.Ability to learn quickly and to creatively solve new problems.Ability to define problems, collect data, establish facts, and draw valid conclusions.Strong work ethic and time management skills to efficiently handle daily claim production goals.Must have ability to interpret and apply provisions of the manuals, SPDs, medical terminology and insurance claims.Excellent verbal and written communication skills.Knowledge of Microsoft Office products and Claims System.EDUCATION AND/OR EXPERIENCE:High School Diploma or General Education Degree (GED), plus 1-3 years adjusting experience. Direct experience adjudicating medical claims or in-depth medical billing knowledge is highly preferred.PHYSICAL DEMANDS:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.While performing the duties of this job, the employee is regularly required to perform keyboard work, verbal communications, and close vision computer use. The employee may need to lift and/or move up to fifteen (15) pounds.HIPAA SECURITY STATEMENT:This position may require access to private health information (PHI) and/or electronic private health information (EPHI) for Loomis Company clients. The minimum necessary access will be granted based on the employee’s responsibilities. To perform their job requirements, certain employees may also be granted access to PHI and EPHI of Loomis Company employees.WORK ENVIRONMENT:The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually moderate.To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, while maintaining regular attendance that is acceptable to company standards. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions