Insurance & Superannuation

FACETS Claims Processor

Sourcedge Solutions

New York · Albany · United States

Job Description Job Description Location: Remote
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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

Reference: 3209640286

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