Claims Examiner Level 1

Job Description

Job Description

Description :

SEIU Healthcare IL Benefit Funds is a dynamic benefits administration organization committed to providing the highest quality health and retirement benefits in the most financially responsible manner, while always acting in the best interest of the union members. The Fund serves over 20,000 union workers in the Nursing Home, Home Care, Child Care and Personal Assistant industries with the delivery of health and pension benefits. Our employees epitomize the Fund’s core values of quality service, interdependence, effectiveness, and accountability, and forge an alliance with one another to carry out our shared mission and common agreements for those we serve.

Position Summary :

The Claims Examiner, Level 1, is responsible for analyzing, processing, and auditing PPO, HMO and other medical claims for plan participants who are union members of SEIU Healthcare Illinois and Indiana (HCII). Claims Examiners are able to handle and accurately adjudicate assigned medical claims following established guidelines and industry best practices with a minimal amount of supervision.

This position must maintain excellent working relationships with peers in the Claims Department and interdepartmentally, vendors, medical providers, plan participants and all key stakeholders related to the Fund Office.

Claims Examiner, Level 1 will be responsible for the following :

Key Duties and Responsibilities :

• Process medical and facility claims in an accurately and timely manner; ensure all necessary information is present including accident details / subrogation form, other insurance information, referral and / or pre-certification, repricing, auditing, and all other information needed to properly process the claim
• Review and adjudicate claims for compliance with contract terms, benefit coverage, and regulatory requirements.
• Review provider reconsiderations and reprocess the claim or generate letter(s) in response to the request.
• Respond to inquiries from coworkers or other departments via email or a ticketing system within three (3) business days.
• Apply appropriate pricing and coding standards (e.g., CPT, ICD-10, System Benefit codes) and reimbursement methodologies to ensure accurate claim payment.
• Process check-run cycles and check run audits when assigned.
• Perform audits of auto-adjudicated claims when assigned.
• Attend meetings with vendors, providers, partnering organizations or any other meeting as assigned.
• Identify and report system issues, test and troubleshoot system configuration, completing reports, and run other system tasks or reports as assigned.
• Monitor pended claims to ensure unnecessary delays are avoided.
• Monitor claims inventory to assure consistent processing time across the plans.
• Correspond to providers, members and external vendors via mail, email or phone.
• Attend and participate in various meetings, including monthly All Staff meetings, department meetings, training sessions, task force or committee meetings, and other meetings as deemed appropriate to share, discuss, and solution for question or error trends, as well as identify potential process improvements.
• Create one-on-one (1 : 1) agendas with the Claims Supervisor using the Purpose, Outcome and Process (POP) Model and keeping thorough notes for each meeting.
• Back-up all duties of the Claims Clerk as needed.

Privacy and Security Responsibilities :

This position requires employees to handle Personal Identifiable Information (PII) and Protected Health Information (PHI) for our members. You will be responsible and accountable for maintaining the confidentiality, integrity, and availability of all PII and PHI. Report any suspected HIPAA violation or breach to our HIPAA Privacy and Security Officer.

Requirements :

Education Requirements :

Job Requirements :

Preferred Skills :

Career Development & Continuing Education Opportunities : Yes

Benefits :

SEIU Healthcare IL Benefit Funds offers a comprehensive health benefits (medical, dental and vision coverage) for employees and eligible dependents, including no employee premium option for employee only; competitive compensation; generous holidays and PTO policies; and a pension retirement plan.

Diversity creates a healthier atmosphere : SEIU Healthcare IL Benefit Funds is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

The SEIU Healthcare IL Benefit Funds vision is to create a more just and equitable society that fosters a lifetime of quality healthcare and financial security for all. We hope that our social justice values and the responsibility we take to operate a socially conscious organization aligns with your professional desire to contribute and serve with purpose.