Summary:
The Claims Examiner resolves a wide variety of claims transactions that may include, but may not be limited to, XC/Aide, Logging/Entry, and pended claims and adjustments processing in accordance with MTM, Corporate strategy, NCQA and mandated requirements. Incumbents exercise accuracy, attention to detail, adherence to desk level procedures, and excellence at all times in responding to internal/external customers, regardless of the issue to meet customer demands. Professionalism, self-directed manner and continuous process improvement are required to ensure and promote customer satisfaction and retention. The B version of this role, requires the individual to adjust, adjudicate and process Article 47 (self- funded) claims.
- In accordance with established departmental procedures, corporate policies, member, group and provider contracts and riders, will process, enter, adjudicate and/or adjust and research claims, request needed information through system generated letters and/or phone calls and work closely with other required internal departments.
- Follows the appropriate procedures to adjudicate, adjust and/or research claims according to contract specifications. Initiates the necessary corrective transactions to clear claims for payment or denial.
- Request further review by completing medical, institutional, utilization and other party liability review database forms.
- Conducts regular and timely follow up on pending claims and adjudicates and/or adjusts suspended claims based on responses.
- Identifies patterns that impact quality, claim inventory and/or customer satisfaction.
- Identifies and follows through on issues (known or potential).
- Responds to internal or external customers in a professional, efficient manner to encourage acceptance of corporate products, services, and policies.
- Participates in the training needed to learn regulations, systems, procedures, develop skills and initiate actions to accurately fulfill all requirements of the job.
- Consistently adheres to all policies, procedures, and performance measures.
- Regular and reliable attendance is expected and required.
- Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
- Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
- Performs additional duties as assigned by Management.
- Entry level – requires little or no previous experience.
- Duties performed under close supervision.
- Attends all training required to become proficient in all aspects of the position.
- Resolves simple claims transactions.
- Duties performed under limited supervision.
- Resolves moderately complex claims processing and simple adjustment transactions.
- Self-directed and dependable. Able to perform complex claims processing and adjustment research transactions under very limited supervision.
- Resolves complex claims and adjustment transactions.
- Initiates involvement for higher level responsibilities or proactively volunteers for assisting in the resolution of escalated or systemic issues.
NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
- Associates degree in Business Administration, Health Care Administration, Health Economics or related or 1 year of transaction processing or customer service experience required; preferably in a health care environment.
- B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.
- Meets or exceeds reasonable expectations for quality, proficiency and production.
- Develops skills necessary to continuously improve.
- Able to efficiently resolve simple claims transactions, through navigating screens on the computer, referencing written policies and procedures and adhering to the most current business requirements.
- Basic computer skills required, including the ability to navigate in a Windows environment. Able to work between multiple programs and applications at the same time.
- Able to communicate effectively and diplomatically.
- Reasoning and problem-solving skills.
- Organizational skills.
- Ability to work effectively as a member of a team.
- Adept at multi-tasking in order to efficiently resolve moderately complex claims processing and simple adjustment transactions.
- Strong organizational skills and ability to prioritize, multitask, and work in fast paced environment and remain professional and focused under multiple pressures and demands.
- B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.
- Highly Skilled at multi-tasking to efficiently resolve a wide variety of complex claims transactions.
- Limited understanding of COB determination.
- Proficient in computer navigation. Very adept at working between multiple programs and applications at the same time.
- Communicating effectively and diplomatically and leading others as this is a demonstrated strength.
- Highly skilled and well-developed reasoning and problem-solving skills.
- Is seen as a subject matter expert and go-to resource by others.
- May be used to mentor and train others.
- B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is required.
Physical Requirements
- Ability to complete work in a traditional office environment under fluorescent lighting.
- Ability to arrive on time at work and as scheduled.
- Ability to meet minimum performance metrics.
- Ability to orally communicate.
- Must be able to function while sitting at a desk viewing a computer and using a keyboard and mouse for 3 or more hours at a time.
- Must be able to travel across the enterprise.
- Ability to work in a home office for continuous periods of time for business continuity.
***********
The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer