Adjudicating claims in assigned work queues based on Centivo’s written Policies and Procedures and the terms of the Summary Plan Documents (SPD’s) for Centivo’s clients.
Diligently reviewing all system-generated edits which have been applied to claims in the Claims Adjustor’s assigned queues prior to releasing the claims to ensure benefits are being applied per the client’s SPD and client funds are being appropriately managed.
When the Claims Adjustor believes there may be an issue or inconsistency in the interpretation of a Plan as the system is applying benefits, immediately route the claim to the Plan Build/System Configuration Team for resolution.
When the Claims Adjustor is unable to resolve an edit based on the provider selection, the pricing and/or usual and customary discrepancies, immediately route the claim to the Provider Maintenance and/or Pricing teams for resolution.
When the Claims Adjustor is unable to resolve an edit based on the information included with or attached to a claim, appropriately deny the claim for additional information, and generate correspondence to the participant or provider concisely explaining data needs. When such additional data is received, reopen the denied claim, and re-adjudicate based on the information.
Maintain daily, weekly, and monthly required production levels documented in Claims Department Policies and Procedures.
Participation in Departmental quality improvement efforts and bring forward process improvement suggestions that will improve efficiencies; question a process or policy that creates additional steps or work on the Claims Adjustor and suggest an alternative solution.
Processes claims in accordance with established policies and procedures, contacting providers as needed, completing tasks under moderate supervision. Responsible for meeting the production and quality goals determined by the department leadership.
Increased responsibilities, which may include assisting and mentoring less experienced team members, participating in various initiatives or projects within the Claims Delivery Team, documenting processes, performing advanced tasks, supporting high-dollar reviews, and overpayments/refunds.
You should have:
Prior experience with a highly automated and integrated claims processing system.
Experience working with HealthRules Payer preferred
