What are the responsibilities and job description for the Medical Claims Adjuster position at SEIU Local 1 & Participating Employer Trust Funds?
Benefits:
Job Summary:
This position is responsible for analyzing and processing facility, ancillary and physician claims, checking them for validity. Medical claims processor reviews claim for various items, including appropriate billing practices, and coverage based on the Health Plan Guidelines and Schedule of Benefits. The Processor must possess knowledge of medical terms, such as Current Procedural Terminology (CPT), Health Care Procedure Coding Systems (HCPCS) and International Classification of Diseases (ICD-10) to review the claim accurately.
Responsibilities
- AD&D Benefit
- Pension Benefit
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Training & development
- Vision insurance
Job Summary:
This position is responsible for analyzing and processing facility, ancillary and physician claims, checking them for validity. Medical claims processor reviews claim for various items, including appropriate billing practices, and coverage based on the Health Plan Guidelines and Schedule of Benefits. The Processor must possess knowledge of medical terms, such as Current Procedural Terminology (CPT), Health Care Procedure Coding Systems (HCPCS) and International Classification of Diseases (ICD-10) to review the claim accurately.
Responsibilities
- Validate information on all medical and disability claims from participants and providers seeking payment from their benefits.
- Request required information from both internal and external sources to establish whether the claim is complete and valid,
- Exercise prudent judgement to determine when claims require repricing, management review, or additional information.
- Communicate effectively with Leadership, cross departments, participants, providers, and vendors to expediently handle claim issues.
- Follow appropriate HIPAA guidelines related to patient privacy and confidentiality.
- Attend and participate in Claims meetings for training purposes.
- Meet and maintain production and audit standard quotas.
- Test and verify new or enhanced system applications, if necessary.
- Examine a claim using plan document, supporting documentation, Knowledge Articles, and other resources to make reasonable decisions regarding proper payment of claims.
- Identify billing trends and/or industry changes to notify management.
- Other duties as assigned.
- Minimum of 2 years of medical claims processing experience
- Bilingual in Spanish Preferred
- Must have general medical terminology and anatomy knowledge
- Ability to read and interpret medical records
- Understand Plan eligibility including excluded and included covered benefits
- Must have good communication skills / Professional telephone etiquette
- Knowledge of the Basys system or similar claim processing systems
Flexible work from home options available.
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