Claims Adjudicator II
1 month ago
UNITE HERE HEALTH serves 190,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity
The purpose of this position is to receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day to day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries.
ESSENTIAL JOB FUNCTIONS AND DUTIES
- Screens claims for completeness of necessary information
- Verifies participant/dependent eligibility
- Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
- Codes basic information and selects codes to determine payment liability amount
- Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
- Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
- Handles the end to end process of Medicare Secondary Payer (MSP) files
- Processes Personal Injury Protection (PIP) claims
- Requests overpayment refunds, maintains corresponding files and performs follow-up actions
- Handles verbal and written inquiries received from internal and external customers
- Processes Short Term Disability claims
- Adjudicates claims according to established productivity and quality goals
- Achieve individual established goals in order to meet or exceed departmental metrics
ESSENTIAL QUALIFICATIONS
Years of Experience and Knowledge
- 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment
- Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
- Working knowledge and experience in Subrogation and its related processes
- Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
- Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes
Hourly range for this position: $20.31~$24.92. Actual hourly rate may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.
Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) with potential for hybrid work-from-home arrangement.
We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).
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