Medical Claims Adjudicator — Detail-Driven Examiner

Jefferson Health Plans; Philadelphia (Philadelphia County); On-site; USD 42,000 - 64,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability insurance

Tuition assistance

Job summary

Health Partners Plans is seeking a Claim Examiner to adjudicate medical claims under supervision in accordance with policies and procedures. The role emphasizes accurate data entry, adherence to processing rules, and timely review of pended claims.

The position requires solid confidentiality practices, excellent communications, and basic computer skills, with a focus on managing care principles within a collaborative health plan environment.

Qualifications

• High School Diploma or GED required.
• Ability to maintain strict confidentiality of patient information.
• Excellent oral and written communication skills.
• Basic understanding of computer applications.
• General understanding of Managed Care concepts.

Responsibilities

• Able to work in a constant state of alertness and safe manner.
• Adjudicates claims in accordance with data entry rules and contractual agreements.
• Reviews pended claims daily to ensure documentation is complete before adjudication.
• Completes service forms for pended claims and routes for resolution.
• Reviews audit results weekly and corrects errors in the claims processing system.
• Follows procedures for claims processing and high dollar claim review.
• Maintains minimum performance standards per departmental policies.
• Keeps current with Claims Department policies and procedures.
• Assists the unit in meeting and maintaining performance standards.

Skills

Confidentiality

Communication skills

Computer literacy

Managed Care knowledge

Claims processing understanding

Education

High School Diploma/GED

Job description

Health Partners Plans is seeking a Claim Examiner to adjudicate medical claims under supervision in accordance with policies and procedures. The role emphasizes accurate data entry, adherence to processing rules, and timely review of pended claims.

The position requires solid confidentiality practices, excellent communications, and basic computer skills, with a focus on managing care principles within a collaborative health plan environment.