Responsible for keying, processing and/or adjusting health claims in accordance with claims policies and procedures.
Works without significant guidance w/ basic understanding of multiple products (HMO, PPO, COB, etc. ).
Must be able to successfully perform all the duties.
Primary duties may include, but are not limited to: Able to handle more complex claims.
Reviews, analyses and processes claims/policies related to events to determine extent of company liability and entitlement.
Researches and analyses claims issues.
Responds to inquiries, may involve customer/client contact.
Requires a HS diploma or equivalent; 0-3.5 years of claims processing experience; previous experience using PC, database system, and related software (word processing, spreadsheets, etc. ); or any combination of education and experience, which would provide an equivalent background.
Excellent knowledge of the various operations of the organization, products, and services.
Good understanding of the application of benefit contracts, pricing, processing, policies, procedures, govt regs, coordination of benefits, & healthcare terminology.
Good working knowledge of claims and products, including the grievance and/or re-consideration process.
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