Claims Processor

JOB SUMMARY

This job screens, reviews, evaluate online entry, error correction and / or quality control review and final adjudication of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. May include initial entry claims or claims which have suspended. Translate foreign language claims into English using software and code appropriately. Convert foreign currency to US dollar and code charges appropriately. Reviews processed claims and inquiries to determine corrective action which can include adjusting claims. Takes the corrective action steps using enrollment, benefit and historical claim processing information.

ESSENTIAL RESPONSIBILITIES

• Determine if claim information is complete and correct. Enter/verify claims data.
• Resolve claim edits, review history records and determine benefit eligibility for service. Review payment levels to arrive at final payment determination.
• Meets all production and quality standards. Attends all required training classes.
• Elevates issues to next level of supervision, as appropriate.
• Maintains accurate records, including timekeeping records.
• Other duties as assigned or requested.

EDUCATION

Required

• High School Diploma/GED

Substitutions

• None

Preferred

• None

EXPERIENCE

Required

• None

Preferred

• Typing speed of at least 60 words per minute

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

SKILLS

• Ability to take direction and to navigate through multiple systems simultaneously.
• Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
• Ability to use mathematics to adjudicate claims.
• Ability to solve problems within pre-defined methods and guidelines.
• Knowledge of operating systems specific to claim processing.

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Never

Travel regularly from the office to various work sites or from site-to-site

Never

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Never

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.

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

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