Claims Clerk

Lumen Solutions Group Inc.; Washington, Baltimore (District of Columbia, MD); Remote; USD 50,000 - 70,000; Full time

Job summary

A leading company is seeking a Claims Processor to review, adjudicate, and ensure the proper handling of claims. The ideal candidate will have a high school diploma and over three years of experience in the field, showing proficiency in analytical skills, communication, and navigating computer systems. This full-time remote role requires adaptability in a fast-paced environment, contributing to quality improvement and customer service excellence.

Qualifications

• More than three years of experience processing claim documents.
• Experience with processing Inter-Plan Teleprocessing System (ITS) Claims.
• Preferred: 5+ years in claims processing, billing, or medical terminology.

Responsibilities

• Examines and resolves non-adjudicated claims to ensure timely payments.
• Completes daily productivity data for leadership's performance statistics.
• Collaborates with multiple departments to resolve processing issues.

Skills

Analytical skills

Reading comprehension

Basic written/oral communication

Navigating computer applications

Education

High School Diploma or GED

Job description

Job Description: FULL TIME REMOTE

PURPOSE:

Under direct supervision, reviews and adjudicates paper/electronic claims. Determines proper handling and adjudication of claims following organizational policies and procedures.

ESSENTIAL FUNCTIONS:

60% Examines and resolves non-adjudicated claims to identify key elements of processing requirements based on contracts, policies and procedures. Process product or system-specific claims to ensure timely payments are generated and calculate deductibles and maximums as well as research and resolve pending claims. The Claims Processor also use automated system processes to send pending claims to ensure accurate completion according to medical policy, contracts, policies and procedures allowing timely considerations to be generated using multiple systems.

25% Completes research of procedures. Applies training materials, correspondence and medical policies to ensure claims are processed accurately. Partners with Quality team for clarity on procedures and/or difficult claims and receives coaching from leadership. Required participation in ongoing developmental training to performing daily functions.

10% Completes productivity daily data that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design and financial planning, etc.

5% Collaborates with multiple departments providing feedback and resolving issues and answering basic processing questions.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: High School Diploma or GED

Experience: more than three years experience processing claim documents. Experience with processing Inter-Plan Teleprocessing System (ITS) Claims.

Preferred Qualifications

5+ years Claims processing, billing, or medical terminology experience

Knowledge, Skills and Abilities (KSAs)

Demonstrated analytical skills, Proficient

Demonstrated reading comprehension and ability to follow directions provided, Proficient

Basic written/oral communication skills , Proficient

Demonstrated ability to navigate computer applications , Proficient

The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.