Investigate and perform adjustment of claims and ensure that claims are handled properly within authority limits, and in line with standard procedures and guidelines. Verifies insurance claims by reviewing claims requirements; examining documentation and calculations; highlighting and summarizing out-of-line situations; recommending changes in operating processes; completing reports, logs, and audit records.
ESSENTIAL FUNCTIONS:
60% Proactively investigate and perform adjustments of claims. Ensure claims are handled within authority limits, and in line with standard procedures and guidelines.
20% Updates claims audit records by entering, verifying, and securing data.
10% Settle standard/complex claims through payment or denial.
5% Provides claims audit information and reports by collecting, analyzing, and summarizing data and trends.
5% Improves claims adjustment job knowledge by attending training sessions
1+ year of Claims Adjustment experience minimum required
The team are using FACETS G6 platform
Medical Claims processing experience. Medical Claims Adjustment experience. .
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: High School Diploma or GED
Experience: 3 years years claims experience and complete understanding of all systems, policies and procedures.
Preferred Qualifications
Knowledge, Skills and Abilities (KSAs)
Ability to analyze information gathered from investigation, Proficient
Excellent communication skills both written and verbal., Proficient
Ability to recognize, analyze, and solve a variety of problems., Proficient
Skill in completing assignments accurately with attention to detail., Proficient
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