Regular
Non-Exempt
General Description
Analyzes, processes, and adjudicates all types of complex claims both in CMS1500 and UB-04 formats using the highest degree of analysis for payment and/or decline in, for example, adjustments, reimbursements to members, grievances, reconciliations, COB, US, non-participants, recovery, reinsurance, and life insurance, among others, and requesting additional information according to the benefits and requirements applicable up to the maximum amount of the adjudication limit established in the current policy and procedure.
Essential Functions
Evaluate and resolve the claims referred to by the previous authorization level and refer to the analyzed claims that require support from another department accordingly.
Processes complex claims, adjustments, COB, samplings, US claims, non-participants, grievances, reimbursements to members, all kinds of adjustments, reconciliations, recoveries, reinsurance, and life insurance, among others.
Refers claims and/or adjustments to areas and/or departments necessary to obtain additional information, the outreach process, and/or approvals for payment adjudication and/or denial.
Executes the average of claims per hour established by MCS (which may vary from time to time), maintaining financial accuracy and processing claims and/or adjustments applicable as established in the current policy and procedure.
Complies with and updates their personal productivity report daily.
Reports to their immediate supervisor any evidence of deficiency in the system configuration of the policyholder's coverage of the contract with the provider that may be detected during the claim adjudication process.
Report any evidence of error in payment or decline that may be detected during the claim adjudication process to the corresponding department and their immediate supervisor.
Report any evidence of utilization or attempted fraud that may be detected during the claim adjudication process to the appropriate department and its immediate supervisor.
Complies fully and consistently with the company's standards, policies, and procedures and the local and federal laws applicable to our industry, business, and employment practices.
May perform other duties and responsibilities as assigned in accordance with the education and experience
requirement contained herein.
Minimum Qualifications
Education and Experience: Four-year high school diploma. Minimum five (5) years of experience as a claims analyst or in a Provider Call Center in the health insurance industry.
OR
Education and Experience: Associate's degree or sixty (60) credits. Minimum four (4) years of experience as a claims analyst or in a Provider Call Center in the health insurance industry.
OR
Education and Experience: Bachelor's degree. Minimum two (2) years of experience as a claims analyst or in a Provider Call Center in the health insurance industry.
"Proven experience may be replaced by previously established requirements."
Certifications/Licenses: N/A
Other: N/A
Spanish – Intermediate (writing, reading, and conversational)
English – Intermediate (writing, reading, and conversational)
"We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.