Walk-in || Claim Adjudicator

Looking immediate joiners only.

Role & responsibilities

• Processes claims in accordance with production, timeliness, and quality standards.
• Participates with other internal departments in the resolution of claims issues across department

lines.

• Ensures claims are processed in compliance with governmental and accrediting agency regulations.
• Ability to read and follow directions
• Ensures the delivery of superior customer services by providing timely and accurate

claims payment and responding timely to member and provider inquiries and

complaints regarding claims processing.

• Develops strong intradepartmental relationships with other department personnel and/or

exempt individual contributors to ensure clear communication and prompt resolution to

issues.

• Follows departmental policies and procedures regarding claims adjudication.
• Ensures that potential fraudulent claims practices are identified and reported to the
• Follows all HIPAA compliance guidelines to ensure protection of member protected health

information.

Preferred candidate profile

• Understanding of hospital and/or physicians contracts to determine payable benefits and

knowledge of pricing DRG, APC and per diem for all Medical claim products.

• Excellent oral and written communication skills including good grammar, voice, and diction.
• Able to read and interpret documents and calculate figures and amounts.
• Proficient in MS Office with basic computer and keyboarding skills.
• Excellent customer service skills (friendly, courteous, and helpful).
• High school diploma or general education degree (GED) required
• Minimum two years experience in managed care claims processing environment required
• Understanding of configuration of claim processing systems and the links between

contracts, utilization management and claims processing within these systems

required

• An equivalent combination of education, training, and experience.