Medical Claims Adjuster

3 weeks ago

Nyack, United States Stafford Communications Full time
Job Title: Medical Claims Adjuster - Remote

Stafford Communications is uniquely different. Stafford Communications, a division of Premier BPO specializes in customer service, compliance and marketing in support of many prestigious brands in in pharmaceutical, healthcare, food, consumer packaged goods and beauty care companies - ensuring their customer service initiatives are aligned to their marketing programs.

Job Summary:

The Medical Claims Adjuster - Remote is responsible for the review, investigation, decision making, and processing of production claim types, and all related claim functions and activities. Production claims are those claims under $5,000.

Essential Duties and Responsibilities:
  • Review and adjudicate all types of claims designated as "production claims", meeting production and quality goals.
  • Review, investigate, and apply all necessary criteria to determine validity of claim.
  • Understand the Anthem JAA workflow and apply JAA processing procedures, rules, and guidelines to adjudicate JAA claims.
  • Apply benefit plan rules and processing guidelines to pay, pend, or deny claims.
  • Manage and follow up timely on all pending claims and correspondence, including review of patient claim history.
  • Prepare and generate accurate claim EOB messages and correspondence.
  • Review and determine eligibility and coverage for specific group/plan.
  • Research claim problems and take necessary actions to resolve.
  • Utilize training and on-line documentation to keep up to date on processing guidelines, insurance principles, DOL rules and regulations, and benefit plan rules.
  • Update claims system with applicable claim/and patient notes.
  • Perform COB, No-fault, Pre-existing, and other claim investigations.
  • Contact employers, providers, participants, as necessary.
  • Identify correct providers, PPOs, and ensure that appropriate pricing is obtained.
  • Perform non-complex claim adjustments, including handling of customer service referrals and take appropriate steps to initiate adjustments on JAA claims.
  • Troubleshoot utilization review and medical necessity related issues utilizing AMM or other UR vendor's website information, and route claims for review accordingly.
  • Utilize Claim Workflow system for work assignments, routing, and follow up.
  • Handle other claim-related duties, projects, and assignments as assigned, including the handling of claim exceptions and provider not found claims.
Education and/or Experience:
  • One to two years of college or equivalent experience.
  • Minimum one years' claims experience.
  • Familiarity with Eldorado Software is a plus.
  • Medical billing and/or AMA coding experience preferred.
  • Data Entry experience or equivalent type work using keyboard/PC.

Knowledge and skills:

•Knowledge of insurance and medical terminology.

•High level of keyboard/PC skills.

•Excellent oral and written communication skills.

•Good judgment and decision-making abilities.

•Good analytical and math skills.

•Good interpersonal skills and willingness to assist others.

•Basic knowledge of Word and Excel.

Pay, benefits and more:

We are eager to attract the best, so we offer competitive compensation and a generous benefits package, including full health insurance (medical, dental and vision), 401(k), life insurance, disability and more.

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