This position is responsible for processing claims in the claims processing system.

• Determine if health claim is payable based on Federal and/or state regulations, plan benefits, provider contracts, as well as policies and procedures. Research via the internet is required in order to obtain necessary information.
• Adjudicate claim via claims processing system
• Review and determine provider and member eligibility
• Review/resolve pended/routed claims on a daily basis.
• Research and resolve claim/customer service inquiries on a daily basis.
• Process non-traditional claims.
• Must meet and maintain established productivity standard.
• Must meet and maintain established quality standard.
• Data entry of claims data into claims processing system may be required.

• High school diploma or equivalent is required
• Computer proficiency including Microsoft Excel, Word and Outlook.
• Extremely strong attention to detail and accuracy
• Solid organizational and critical thinking skills
• Basic math skills
• Ability to work independently
• Experience meeting deadlines and performing required functions under pressure on a routine basis
• Excellent verbal and written communication skills
• Overall performance accountability (attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation)
• Ability to explain rationale behind claim decisions
• Ability to work overtime as required by management
• Understanding of provider contract and medical terminology.
• Prior health claim processing preferred.

• High school education required