Claims Processor

As a Claims Processor, you will play a pivotal role in ensuring the efficiency and accuracy of claims processing within our organization. Your responsibilities will encompass a wide range of tasks, including year-end processing, managing adjustments, coordinating benefits, handling subrogation and high-dollar claims, processing Medicaid claims and complex appeals, and engaging in hospital audits.

The essential functions include, but are not limited to the following:

• Year-End Processing: Oversee and facilitate the year-end processing activities to ensure timely and accurate closure of claims records.
• Adjustments Management: Process adjustments to claims as needed, ensuring proper documentation and adherence to company policies and procedures.
• Coordination of Benefits: Manage coordination of benefits for claims.
• Subrogation and High-Dollar Claims: Handle subrogation claims and high-dollar claims, applying sound judgment and attention to detail in reviewing and processing these complex cases.
• Process refund requests.
• Medicaid Claims and Complex Appeals: Process Medicaid claims and assist in handling complex appeals, demonstrating a thorough understanding of Medicaid regulations and procedures.
• OGA Coordination: Manage chats with OGA and provide accurate answers to inquiries related to claims processing, demonstrating strong communication skills and a deep understanding of our processes.
• Hospital Audits: Conduct hospital audits to ensure compliance with contractual agreements and regulatory requirements.
• Case Management Reports: Analyze case management reports and make sure they are filed to the correct member.

• Bachelor's degree in business administration, healthcare management, or a related field preferred. Equivalent work experience may be considered.
• Experience: Minimum of 3 years of experience in claims processing or related field.
• Strong understanding of claims processing procedures, including familiarity with medical terminology and insurance policies
• Highly detail-oriented with a focus on accuracy and quality assurance in claims processing
• Strong analytical and problem-solving skills with the ability to identify root causes and develop solutions.
• Experience in handling escalated issues and making sound decisions under pressure.