Summary / Objective:

The Senior Claims Adjudicator is responsible for the accurate and timely entry, review, and resolution of simple to moderate complexity medical claims in accordance with policies, procedures, and guidelines as outlined by the company.

Essential Functions:

• Tracking claims financial transactions including claims payment, claims refunds, and claims recoups, with a high degree of accuracy within the compliance deadlines.
• Prepares, processes and distributes claims checks to include creating and maintaining check processing files.
• Research, process, recoup, appeals and refund requests.
• Serves as a customer service representative of PSW for our members, physicians and vendors to include phone and fax coverage, mail and follow up on customer service issues.
• Communicate efficiently with members and providers or others regarding claim benefit questions or information.
• Adjudicates claims in accordance with Medicare, Medicare Advantage & department guidelines/policies.
• Provides supervisor with suggestions on how to streamline processes based on daily activities.
• Exceed customer expectations by providing professional and personalized service at all times.
• Is aware of and supports strategic plans that ensure department and/or company objectives and goals are obtained. Implement new policies, procedures and company initiatives as assigned and ensures all areas are maintained in accordance with company policy, state, federal and plan regulatory mandates.
• Builds and leverages cross-functional collaborative relationships to facilitate a team-work oriented atmosphere and achieve company goals.
• Continually review assigned areas of responsibility and give suggestions to supervisor on how to enhance service/products.
• Continue own education by staying informed of industry trends and actively participating in trainings provided by the company.
• Ensures compliance with PSW policies and procedures with special emphasis on compliance with HIPAA requirements.

Required Education and/or Work Experience:

• Experience with payment rules and fee schedule for Medicare or Medicare Advantage.
• Three + (3) years of claims adjudicator experience in setting that demanded accuracy and quantity or combination of education/experience.
• Strong ability to be detail attentive.
• Knowledge of claims payment or billing and coding structure.
• Experience with understanding of insurance benefits, provider contracts, and medical records.

Preferred Education and/or Work Experience:

• Experience with EZ-CAP or strong familiarity with other claims database software.
• Certified coder accreditation.

Benefits:

• 401(k)
• 401(k) matching (4%)
• Dental insurance
• Disability insurance
• Flexible Spending Account
• Health Savings Account
• Health Savings Account matching
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance