Claims Processor I

Researches and verifies complex claims information to ensure the accurate and timely processing of claims. Enters all information needed to process claim. Identifies inconsistencies and makes necessary corrections. Accountable for complying with all laws and regulations associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: SUPERVISOR, CLAIMS OPERATIONS
• Necessary Contacts: In order to effectively fulfill this position, the Claims Processor I must be in contact with: Various internal departments and staff including, but not limited to, Provider Services, Legal, Internal Audit, IT, other Benefits Operations Management and staff, Membership and Billing, Administrative Services, and District Offices. Various external entities including, but not limited to, Providers, Members, Lawyers, Groups, Commissioner of Insurance, other insurance companies, and other Plans.

• High School Diploma or equivalent required
• Associate's is preferred

• 1 year of related clerical or data entry is required
• A medical office or medical coding diploma can be used in lieu of the one year of experience
• Completion of the Medical Assistant, Coding & Insurance Pathway from BRCC, can be used in lieu of the one year of experience.
• Claims processing or claims coding experience is preferred

• Must be able to enter data at 4000 keystrokes per hour
• Medical coding training is preferred
• Must be able to demonstrate critical thinking and problem solving skills
• Familiarity with medical and health insurance terminology preferred
• Demonstrated verbal and written communication skills with the ability to interpret and communicate information with tact, diplomacy, patience and professionalism.
• Must demonstrate PC skills including Microsoft Office (e.g., Word, Excel, Outlook, etc.)

• None Required

• Reviews and corrects scanned claims documents upon receipt as well as enters coded information, checks claims for completeness and accuracy of information prior to final entry, while identifying and resolving inconsistences, and appropriately returns claims requesting missing information in accordance with established quantity, quality, and timeliness guidelines ensuring contract benefits are applied correctly, ultimately providing a high degree of customer satisfaction.
• Consistently researches procedural questions using supporting documentation while identifying incomplete adjudication instructions found within the supporting documentation, allowing for participatory suggestions for updating and correcting procedures, identifies training issues, and appropriately checking with management when necessary, to provide excellent quality in claims adjudication.
• Maintains and records information necessary for accurate recording and calculation of production, which include number of edits processed, hours worked, downtime and special projects assignments daily. This information is retained as historical data which is needed to continually refine and define the claims processor position as needed to ensure high customer satisfaction.
• Rejects, redirects misrouted or sends back claims when information is incomplete or inaccurate to facilitate timely processing ensuring that claims are processed according to departmental guidelines and assist with customer service.
• Researches procedural questions in training manual.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.