FACETS Claims Processor
- Job Title
- FACETS Claims Processor
- Requirement ID
- 27712691
- Begin Date
- 9/12/23
- Duration
- Location
- Albany, NY 12212
- Other Location
- Description
-
Location: Remote
Reply at: Jobs@sourcedge.com
FACETS SENIOR CLAIMS PROCESSOR
Job Description:
- 5 Years Facets Claims Adjudication Experience
- The Claims Examiner must maintain production and inventory standards compliant with Claims Administration requirements
- High school diploma or equivalent required
- Must have 5+ years of relevant claim processing experience in healthcare industry (managed care or TPA Company) to support our clients
- Possess high productivity and quality standards within a claims processing automation environment
- Knowledge of CPT, HCPC, ICD-10 codes
- Knowledge of HMO, PPO, Medicare and Medicaid plans
- Knowledge of Medical terminology
- Computer with 2 Monitors
- High Speed Internet Connection
- Ability to work remote 8 hour day, Mon-Fri.
Responsibilities:
- The claims examiner is responsible for accurate and timely adjudication of claims for the Health Plans lines of business
- Primary duties include analysis and resolution of claims, including reviewing pended claims and manually resolving based on client specified direction and criteria, including third-party liability claims
- The claims examiner must be able to work independently, effectively prioritizing work in a production environment that frequently changes to meet production standards and contractual requirements
- Success in this position will be based on the individual's ability to effectively prioritize work, identify, and resolve complex concerns in a professional manner, and work in a team environment to achieve and maintain production and audit standards
- Timely and accurate processing and adjudication of all types of claims from assigned workflow queues
- Compliance with state, federal and contractual requirements to Claims Administration
- Demonstrate a thorough knowledge of the Plan's claims processing procedures as provided in training materials and proficiency with the core and ancillary system applications
- Demonstrates the ability to think analytically to resolve complicated claim issues and identify appropriately when to escalate issues for review
- Ability to review and apply Plan directives and desktop procedures to claims, following step by step guidelines
- Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate
- Complete all mandatory claims training/refresher courses
- Actively participates and supports department and organization-wide efforts to improve efficiencies while supporting departmental goals and objectives
- Complete all mandatory compliance and corporate training
- Must be able to adapt to a changing work priorities and requirements and perform other duties as directed to support the overall functions of Claims Administration and support of staff without boundaries within the Plan
- Required Skills
-
FACETS Claims Adjudication
- Openings
- 2
