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Claims Evaluation Specialist

2 months ago

West Burke, Vermont, United States University Health System Full time
POSITION SUMMARY/RESPONSIBILITIES

Conduct thorough analysis of intricate issues related to claim reimbursements, eligibility criteria, insurance coordination, transplant services, and systemic challenges that exceed the capabilities of claim examiners and senior claim examiners impacting claims processing.

Serve as a consultant to claims personnel in resolving complex claim matters. Collaborate effectively with the Configuration team in validating contracts utilized in operational processes and reporting to ensure automated adjudication. Adhere to company standards and policies in all activities. Foster positive relationships within the department, across other departments, and within the organization. Function with minimal supervision.

EDUCATION/EXPERIENCE

A high school diploma or GED equivalent is mandatory. A minimum of five years of experience in HMO/PPO claims processing is essential. Familiarity with the Amisys claims processing system is preferred. Comprehensive knowledge of all benefit programs provided by the organization, including Medicaid, HMO, PPO, and ASO, is required.