Claims Adjuster Blue Card-3 OPEIU

Highmark Health; New York (NY); Hybrid; USD 46,000 - 47,000; Full time

Job summary

Highmark Inc. in New York state seeks a claims reviewer to provide complete, accurate, and timely review and adjustments of Blue Card claims in accordance with contracts and procedures.

The role is bargaining unit based with travel 0%–25%. You will respond to inquiries, document production, and ensure HIPAA compliance while delivering professional service to internal and external customers.

Qualifications

• Healthcare or insurance related experience; claims processing experience; knowledge of medical terminology.
• Preferred previous claims processing or equivalent experience.

Responsibilities

• Adjusts Blue Card claims under provisions of contracts and procedures using the claims administration system.
• Identifies potential fraudulent cases and forwards to Special Investigations.
• Identifies opportunities to resolve issues for the customer via process improvements.
• Provides documentation to management for recommendations on procedural changes.
• Initiates correspondence and/or telephone contact related to claims administration and assignments.
• Responds to written and verbal inquiries from customers.
• Maintains accurate daily production records and confidentiality per HIPAA.
• Delivers service to customers in a professional and efficient manner.
• Performs duties efficiently and as assigned.

Skills

Healthcare experience

Claims processing

Medical terminology

Education

High School/GED

Job description

Company : Highmark Inc.

Job Description : JOB SUMMARY Provides customers with complete, accurate and timely claims review and performs adjustments of claims relative to Blue Card claims administration and claims related tasks. This is a bargaining unit position. The collective bargaining agreement for this position requires that candidates and employees reside in the following counties in the State of New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, or Wyoming.

ESSENTIAL RESPONSIBILITIES

• Adjusts Blue Card claims under provisions of applicable contracts, provider operating agreements and corporate procedures through the performing of on-line transactions and /or adjustments utilizing the corporate claims administration system.
• Identifies potential fraudulent cases and forwards to Special Investigations Department for further review.
• Identifies opportunities to resolve issues on behalf of the customer, through process improvement requests.
• Provides necessary documentation to management for recommendations on changes in departmental procedures/desk levels.
• Initiates correspondence and/or telephone contact incidental to general claims administration/adjustments and/or assignments.
• Answers written and/or verbal inquires/correspondence from internal and/or external customers.
• Maintains accurate daily production records as needed.
• Maintains confidentiality and adheres to HIPAA regulations.
• Delivers service to internal and/or external customers in a professional, polite and efficient manner.
• Performs all job duties efficiently and at an acceptable rate of performance.
• Other duties as assigned or requested.

EXPERIENCE

Required Healthcare or insurance related experience; claims processing experience; knowledge of medical terminology. Preferred Previous claims processing or equivalent experience.

SKILLS

• Must meet minimum qualifications to perform the job including satisfactory completion of all training and testing, inlcduing Basic Computer Literacy test, Typing Skills: 30WPM, and Job Content test.
• Ability to multitask if fast paced environment.
• Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills.
• Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner Ability to utilize basic office equipment.
• Problem Solving. Identified issues and problems; identifies opportunities for improved claims processing.

EDUCATION

Required High School/GED Preferred None

LICENSES or CERTIFICATIONS

Required None Preferred None

Language (Other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type Office- or Remote-based Teaches / trains others Occasionally Travel from the office to various work sites or from site-to-site Rarely Works primarly out-of-the office selling products/services (sales employees) Never Physical work site required No Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Rate

Pay Rate: $22.46 The starting hourly rate for this position listed above is for new employees. This rate has been established by the Local 153, Office and Professional Employee International Union (OPEIU) collective bargaining agreement (CBA) and is non-negotiable. If the successful candidate is currently a bargaining unit member of the OPEIU, hourly rate is commensurate with their anniversary year and pay grade as per the CBA.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at [e-mail] California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.