Medical Claims Representative

• Examines, enters and accurately adjudicates medical, dental, vision, HRA, FLEX, or STD claims based upon coverage, policy and procedural guidelines
• Enters paper claims into a proprietary claim adjudication system
• Adjudicates both paper and electronic claims with 99% accuracy for payment dollars and claim coding following an extensive on-the-job training class
• Maintains strict first-in/first-out for claims adjudication
• Follows office procedures for follow-up on claims needing additional information by reviewing the Holding for Information Report for each assigned client on a monthly basis
• Adjudicates prescription claims not automatically adjudicated by the claim adjudication system
• Interprets COB and Medicare worksheets as needed on assigned clients
• Batches adjudicated claims according to client preference or schedule
• Reports to clients on a weekly basis the total of all claims processed for that client, requesting the funding or requesting that funding be transferred to Pro-Claim
• Communicates with brokers, agents and clients regarding high dollar cost claims and SPEC claimants

• High School Diploma or GED required
• Medical terminology and medical claims experience with involvement in reviewing and analyzing claims is beneficial
• Must be able to work well independently and in a team atmosphere
• Ability to maintain a departmental accuracy standard of 99%
• Detail oriented
• Ability to manage multiple priorities that change from day-to-day and week-to-week in a fast-paced environment
• Ability to understand system calculations in order to determine if claims are adjudicating accurately
• Ability to manually process claims in the claims adjudication system if necessary
• Must understand complicated benefit designs
• Ability to self-manage, prioritize and meet specific production deadlines
• Computer experience, including Word, Excel, and Outlook
• Accurate 10-key and/or data entry skills

Medical terminology and medical claims experience with involvement in reviewing and analyzing claims

• Medical, vision, dental, and life and disability insurance
• Eligible to enroll in company 401(k) plan