Claims Processor

GENERAL FUNCTION
The Claims Coordinator accurately and efficiently processes all types of claims from source documents, maintaining compliance with the insurance plan requirements and with high regard for adhering to goals for quality and claims production rates. Also performs other complex claim processing which include but not limited to Medicare/Medicaid Pend process, Corrected Claims, and running daily reports.

MAJOR DUTIES AND RESPONSIBILITIES
" Efficiently and accurately processes a variety of vision insurance claims or adjustments.
" Determines any special plan requirements prior to billing.
" Reviews claims before entry for completeness and compliance with business requirements.
" Effectively and accurately reviews images and transcribed data in the portal in preparation for auto adjudication.
" Coordinate and complete claim error corrections
" Maintains the Medicare/Medicaid Pend Claims process
" Participates on special project initiatives, including rework efforts as needed.
" Understands and quickly operationalizes processing changes resulting from new plans, benefit designs.
" Maintains compliance with HIPAA guidelines and regulations.
" Works with supervisor and co-workers to provide strong customer service and communication with key customer interfaces that include Account Managers, Operations, Information Systems, Client Representatives and leadership team.
" Assists Team Lead in a backup lead capacity
" Assists with root cause analysis of claim issues to resolve thoroughly and completely for clients
" Contacts stores or providers (when necessary) to obtain additional information or follow up on claims.

BASIC QUALIFICATIONS
" High School diploma or equivalent work experience
" 3 year(s) of data entry experience
" Strong customer service focus
" Strong verbal & written communication skills
" Able to multi-task and prioritize issues
" Strong attention to details

PREFERRED QUALIFICATIONS
" Knowledge of Medicare/Medicaid business
" Knowledge of vision benefits and/or insurance industry
" Proficient in Microsoft Word, Excel and Access