Job Title: Claims Processor Department: Operations Supervisor: Manager, Claims Operations Summary: Position is responsible for the timely and accurate claims adjudication and regulatory reporting functions including associated processes and reporting of key performance indicators. Position is also responsible for responding to incoming inquiries and coordination with other internal and external stakeholders to resolve the issue, determine the underlying cause and make recommendations regarding system changes that may be relevant. Essential Duties and Responsibilities include the following. Other duties may be assigned. Utilizing consistent standards, practices, and processes focused on timely and accurate adjudication of claims to review, evaluate and/or quality control review and final adjudication of paper/electronic claims for inpatient, outpatient and professional medical claims Resolve claim edits, review history records and determine benefit applicability for service including the review of pricing at final payment determination Works closely with stakeholders including clinical, operations and finance teams during the development of key workflows to ensure alignment of overall objectives and key requirements Shall perform user acceptance testing for any impacted changes to claims processing as directed Meets or exceeds production and quality standards including maintaining accurate recording and calculations as required Takes corrective action steps in collaboration with other business units including enrollment and benefits configuration Monitors claim inventory levels Consistently researches procedural questions using supporting documentation while identifying incomplete adjudications instructions found within the supporting documentation, allowing for participatory suggestions for updating and correcting procedures, identifies training issues and appropriately checking with management when necessary, to provide excellent quality in claims adjudication Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization Monitors system and reporting for volume shifts Candidate Qualifications Education Education: High School Diploma or equivalent required Licenses/Certification: None required; CPC preferred Ability to work from home with appropriate internet access and a quiet and private workspace. Skills Minimum two (2) years of claims and health care administration and/or managed care experience Strong knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, DSNP, etc…) Extensive knowledge of claims policies and procedures including regulatory requirements and industry standards from AMA, CMS and CCI edits. Strong computer skills, specifically with Microsoft Office and Windows. A desire to serve others while being empathetic with the drive to go above and beyond to help resolve questions at the first point of contact Must have a strong work ethic and a sense of responsibility to other team members and external stakeholders to meet all needs represented by a robust sense of accountability Adaptable and a quick learner, willing to change to meet shifting customer and business needs. Excellent verbal and written communication skills Extremely organized and detail-oriented. Ability to work independently on a variety of projects in a high volume, fast paced, and sometimes nebulous environment required