Claims Processor II

Reviews and adjudicates complex or specialty claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Assists in training or mentoring new staff members.
• 70% Examines and processes complex or specialty claims according to business/contract regulations, internal standards and examining guidelines. Enters claims into the claim system after verification of correct coding of procedures and diagnosis codes. Verifies that claims have been keyed correctly.
• 15% Ensures that claims are processing according to established quality and production standards. Corrects processing errors by reprocessing, adjusting, and/or recouping claims.
• 15% Researches and resolves claims edits and deferrals. Performs research on claim problems by utilizing policies, procedures, reference materials, forms and coordinates with various internal support areas. Responds to routine correspondence and completes spreadsheet if applicable.

Required Skills and Abilities:

Strong organizational, analytical and judgment skills. Strong oral and written communication skills. Proficient in spelling, punctuation and grammar. Proficient in basic business math. Ability to handle confidential or sensitive information with discretion.

Required Software and Tools: Microsoft Office.

Preferred Skills and Abilities: Strong time management skills. Knowledge of mathematical and statistical concepts.

Preferred Software and Other Tools: Proficient in word processing and spreadsheet applications. proficient database software skills. Work Environment: Typical office environment.