Claims Processor Specialist

Independently processes medical, dental and/or hospital claims, including more difficult or complex claims, provides customer service, and handles special projects and complex functions, including subrogation; acts as a "lead" and resource for other claims processing positions.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities


* Processes medical, dental and/or hospital claims; processes complex claims independently.


* Provides customer service by responding to and documenting telephone and/or written inquiries.


* Meets quantity and quality claims processing standards.


* Performs pre-authorizations, audits files, requests check tracers and stop payments, and assists with researching and preparing appeals, as applicable.


* Maintains current knowledge of assigned Plan(s) and effectively applies knowledge in the payment of claims, customer service and all other job functions.


* Handle special duties and higher level, more complex functions (i.e.

third party liability/subrogation, Flex, re-insurance, PPO updates, life insurance, etc.) as assigned.


* Acts as a resource or "lead" for all processor positions by answering questions, providing assistance, conducting training, and providing back-up on all other accounts.


* Consistently meets established performance standards and demonstrates excellent attendance and punctuality.


* Performs other related duties and special projects as assigned.

Working Conditions/Physical Effort


* Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements.


* May be subject to interruptions.


* May be required to lift a maximum of 25 lbs.


* Must be able to have flexible work schedule when workflow requires.


* Must meet established attendance and punctuality guidelines.

Minimum Qualifications


* High School Diploma or Equivalent.


* Three years of experience processing all types of group medical, dental and hospital claims; in-depth knowledge of benefits, claims adjudication principles and procedures, medical and/or dental terminology and ICD-9 and CPT-4 codes.


* Excellent organizational skills, attention to detail, and ability to interact effectively with others.


* Effective oral and written communication skills.


* Excellent mathematical aptitude.


* Solid organization skills with strong detail orientation/high degree of accuracy.


* Possess a strong work ethic and the ability to work effectively in a team environment.


* Highly developed sense of integrity and commitment to customer satisfaction.


* Ability to communicate clearly and professionally, both verbally and in writing.


* Ability to type 35 WPM and use a 10-key; proficient PC skills, including MS Word and Excel.


* Ability to perform well unde...