Medical Claims Adjuster I

your Jared; Northern (KY); Hybrid; USD 36,000 - 48,000; Full time

Job summary

PEHP Health & Benefits, a division of the Utah Retirement Systems, seeks an attentive claims processor to support medical and Medicare claims processing with accuracy and efficiency.

The role requires reviewing claims, verifying eligibility, and applying policy guidelines while maintaining confidentiality and meeting deadlines. A high school diploma and at least one year of related experience are preferred, with remote work available for most days.

Qualifications

• High School diploma required; one year of work experience preferred in claims processing or related admin work.
• Must possess strong attention to detail and accuracy when reviewing claims and patient data.
• Strong communication skills, both verbal and written, for member and team interactions.

Responsibilities

• Receives and enters medical and/or Medicare claims for payment under medical and/or Medicare Supplement plans.
• Reviews claims for accuracy and completeness, verifies coverage and eligibility of patient.
• Adjudicates routine and complex claims according to established policy guidelines.
• Processes coordination of benefits on Medical and Dental claims.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality.
• Performs other related duties as required.

Skills

Claims processing

Attention to detail

Communication

Teamwork

Multitasking

Education

High School diploma

Job description

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah's public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.For most jobs, remote work is available for 9 out of every 10 workdays.

POSITION SUMMARY

This position plays a critical role in PEHP's efforts to serve and create value for our members by processing a variety of medical claims proficiently and timely. The position includes a variety of professional duties related to processing claims. Successful performance for this position requires an attention to detail, the ability to learn complex claims processes while managing multiple diverse tasks, and a high level of commitment and dependability.

ESSENTIAL JOB FUNCTIONS AND DUTIES

1. Receives and enters medical and/or Medicare claims for payment under medical and/or Medicare Supplement plans.
2. Reviews claims for accuracy and completeness, verifies coverage and eligibility of patient.
3. Adjudicates routine and complex claims according to established policy guidelines.
4. Processes coordination of benefits on Medical and Dental claims.
5. Maintains regular and reliable attendance.
6. Maintains strict confidentiality.
7. Performs other related duties as required.

Education and Experience

High School diploma and one (1) year of work experience.

Specific experience in claims processing, and various administrative functions is preferred, or an equivalent combination of education and experience.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Requires working knowledge of:

• Intricacies related to medical, dental, pharmacy, and Medicare Supplement claims.
• Procedures and processes; intricacies related to medical, mental health and chiropractic claims
• CPT, ICD-10-CM and HCPC's coding and medical terminology
• Various office management systems related to alpha and numeric record keeping
• Personal computer operations and various program applications
• Some knowledge of 10 key operation
• Mathematical skills

Must possess excellent communication skills:

• Interpersonal communication skills; telephone etiquette
• Communicate effectively verbally and in writing

Must have the ability to:

• Analyze a variety of routine claims management issues and problems and make routine corrections
• Maintain a strong attention to detail.
• Follow written and verbal instructions.
• Prioritize work, multi-task, follow through with assignments, and perform within deadlines.
• Deal effectively with stress caused by workload and time deadlines.
• Work well in a team environment as well as independently.
• Follow through with assignments.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.