Processes paper and electronically submitted claims, manages claims reports, handles claims issues and claim adjustments. Supports operational processes and communicates issues clearly. Accurately provides service to all clients, applying client and market specific processes when applicable.
- Supports the processing team and learns specifics of each client and process.
- Processes paper and electronically submitted claims.
- Performs manual entry of claims unable to be scanned through the OCR process.
- Researches and resolves adjustment inquiries when routed from customer service to the adjustment queue.
- Performs edit resolution from pended paper and electronic claims using sound judgment for accurate claims processing.
- Works electronically and paper corrected claims, performing side-by-side comparison and making corrections in Facets.
- Issues form letters and forms, when appropriate.
- Works reports, which involves decision making on adjustments, overrides of co-payments, coinsurance, correct pricing and provider selection.
- Handles difficult situations and acts urgently when necessary per departmental guidelines.