Claims Processor I

Job Title: Claims Processor I

Client: Health Care Insurance
Duration: 12 Months
Location: Fairfax VA 22031 (100% remote however the resource must reside in District of Columbia Maryland Virginia(DMV))

Purpose:

Under direct supervision reviews and adjudicates paper/electronic claims. Determines proper handling and adjudication of claims following organizational policies and procedures.

Essential Functions:

• 60% Claims Examination and Resolution:
  • Examine and resolve nonadjudicated claims.
  • Identify key elements of processing requirements based on contracts policies and procedures.
  • Process product or systemspecific claims to ensure timely payments.
  • Calculate deductibles and maximums.
  • Research and resolve pending claims.
  • Use automated system processes to ensure accurate completion according to medical policy contracts and organizational procedures.
• 25% Research and Procedure Application:
  • Complete research of procedures.
  • Apply training materials correspondence and medical policies to ensure accurate claims processing.
  • Partner with the Quality team for clarity on procedures and difficult claims.
  • Receive coaching from leadership.
  • Participate in ongoing developmental training.
• 10% Productivity Reporting:
  • Complete daily productivity data.
  • Provide reports used by management for scheduling quality improvement initiatives workflow design and financial planning.
• 5% Collaboration:
  • Collaborate with multiple departments.
  • Provide feedback resolve issues and answer basic processing questions.

Qualifications

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Education Level: High School Diploma or GED
• Experience: Less than one year experience processing claim documents

Preferred Qualifications:

• 13 years of claims processing billing or medical terminology experience

Additional Skills:

• Previously processed 200300 medical claims daily in prior roles.

Knowledge Skills and Abilities (KSAs)

• Demonstrated analytical skills proficient
• Demonstrated reading comprehension and ability to follow directions proficient
• Basic written/oral communication skills proficient
• Demonstrated ability to navigate computer applications proficient

The incumbent is required to immediately disclose any debarment exclusion or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fastpaced environment with frequently changing priorities deadlines and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer including customers who may be demanding or otherwise challenging.

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