Job Summary:

• Review and take appropriate action on items assigned to them in the PM Workbasket
• Monitor outstanding requests to ensure completion of review within designated SLAs.
• Interact in a friendly and professional manner with all customers, internal and external.
• Meet or exceed customer and Asurion standards for timeliness, accuracy, and volume of claims handled.
• Work with Investigators and Analysts as appropriate to identify newly emerging fraud patterns.
• Identify and effectively communicate process/system issues to the correct person.
• Participate in team discussions to facilitate the improvement of current processes.
• Ability to prioritize, plan and manage a high-volume workload
• Demonstrate a strong commitment to the mission and values of the organization
• Document all non-standard processes in the claim notes.

Skills on Resume:

• Problem-Solving Skills (Hard Skills)
• Time Management (Soft Skills)
• Customer Service (Soft Skills)
• Communication Skills (Soft Skills)
• Analytical Skills (Hard Skills)
• Documentation Skills (Hard Skills)
• Process Improvement (Hard Skills)
• Organizational Commitment (Soft Skills)

Job Summary:

• Reviews all claims deputies for all product lines and determines the proper disposition of each dispute based on contract and benefit standards and meets all contractual requirements.
• Maintains all claims dispute logs and produces claims dispute reports.
• Attends all grievance and appeals committee meetings and participates in process improvements centered on claims disputes.
• Provides education and/or training
• Collaborates with and supports other departments in reducing the number of claims disputes.
• Requests, organizes and chairs meetings and/or workgroups regarding claims disputes.
• Performs weekly self-audits to ensure compliance with regulatory and contractual requirements.
• Consistently participates in continuing education programs, classes and/or certifications to remain current with updates/changes/additions to regulatory requirements.
• Works independently under general supervision using structured work procedures. 
• Makes judgments within a defined framework
• Coordinates review of claims disputes with other staff members and other departments.

Skills on Resume:

• Claims Analysis (Hard Skills)
• Record Keeping (Hard Skills)
• Process Improvement Participation (Soft Skills)
• Educational Training (Soft Skills)
• Interdepartmental Collaboration (Soft Skills)
• Meeting Facilitation (Soft Skills)
• Regulatory Compliance (Hard Skills)
• Continuing Education (Soft Skills)

Job Summary:

• Handling new loss submissions across all lines of business and all claim systems
• Review claim and policy information to provide background for investigation.
• Determine nature of loss, coverage provided and extent of damage
• Triaging personal line claim submissions to determine if Straight Through Processing (STP) eligible
• Evaluates the facts gathered through the investigation to determine the compensability of the claim.
• Informs insureds, claimants, and attorneys of claim denials when applicable.
• Prepares reports on investigations, settlements, denials of claims and evaluations of involved parties, etc.
• Review the claim status at regular intervals and make recommendations to the Team Leader to discuss problems and remedial actions to resolve them.
• Follow policies and procedures to maintain efficient and compliant operations
• Authorizing claims for all lines of business within a set authority limit.
• Proactively process claims transactions including contractual checks within TAT/accuracy and quality parameters.
• Contribute to overall department success by participating in department initiatives

Skills on Resume:

• Claims Handling (Hard Skills)
• Policy Analysis (Hard Skills)
• Damage Assessment (Hard Skills)
• Claim Triage (Hard Skills)
• Investigative Reporting (Hard Skills)
• Communication (Soft Skills)
• Regulatory Compliance (Hard Skills)
• Team Collaboration (Soft Skills)

Job Summary:

• Review claims for accuracy of submission (clean vs. unclean).
• Adjudicate claims ensuring that eligibility (including COB), referral/authorizations, and payments are appropriate based on contracts, regulations, industry claim payment standards and MCO policies and procedures.
• Evaluate the appropriateness of denials and create proper denial notifications and documentation.
• Research and resolve any disputed claim payments returned from providers.
• Identify TPL and properly process the claim and notify the appropriate area for handling
• Complete pending items within 55 days and accurately provide written documentation.
• Meet established production standards and quality standards consistently.
• Must be able to get along with others, be a team player, accept constructive criticism from the supervisor and be able to follow work rules
• Researching claims, provider contacts, returned mail and claim appeals
• Maintaining logs and reporting information
• Processing Nevada Medicaid claims per defined criteria and instructions
• Outreach to assist the provider community

Skills on Resume:

• Claims Adjudication (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Documentation Skills (Hard Skills)
• Conflict Resolution (Soft Skills)
• TPL Identification (Hard Skills)
• Quality Assurance (Hard Skills)
• Team Collaboration (Soft Skills)
• Provider Outreach (Soft Skills)

Job Summary:

• Be responsible for attending and completing the training scheduled by the client and employer
• Be responsible for processing assigned claims based on client-specified guidelines
• Be responsible for meeting claims productivity targets of claims per hour or day
• Collaborate with other team members on special projects by the team leads including process documentation, training, quality audit
• Assist with surge activity for client (s), or any other project
• Develop Knowledge of physician practice and hospital coding, billing and medical terminology, CPT, HCPCS, ICD-9 and ICD-10, UB04, CMS 1500, authorization and other terms, terminology and concepts of healthcare
• Develop some level of communication with client Claims managers to address issues, and concerns and take preventive measures to avoid service quality issues
• Be responsible for attendance, time off and reporting shift timings, etc. with the prime objective of meeting and exceeding customer deliverables
• Participate in meetings and project activities outside of the primary location at locations determined by the UST management team and team lead
• Excellent attention to detail and time-management skills.

Skills on Resume:

• Client Training (Soft Skills)
• Claims Processing (Hard Skills)
• Productivity Management (Hard Skills)
• Team Collaboration (Soft Skills)
• Project Assistance (Soft Skills)
• Medical Coding Knowledge (Hard Skills)
• Client Communication (Soft Skills)
• Time Management (Soft Skills)

Job Summary:

• Ensures adjudication of assigned medical claims in an accurate and timely manner including the completion of adjustments, recovery of funds, member service incident reports, and the coordination of benefits.
• Verifies adjudicate claim payments independently and by plan guidelines. 
• Claim payments must be directed and approved by the Claims Manager before adjudication.
• Provides timely and accurate information to plan members and providers regarding claims, benefits, member out-of-pocket expenses, and payments via telephone or in writing.
• Works independently under general supervision using structured work procedures. 
• Makes judgments within a defined framework.
• Technical verification of reinsurance account submissions from the clients through broker intermediaries as per the treaty agreement.
• Clarify deviations, and incorrect data with SR's internal departments and/or with the clients
• Financial settlement with broker intermediaries and clients by treaty terms and conditions and managing overall timely cash flow
• Work collaboratively across teams, functions and regions and support the requirements of internal stakeholders
• Ensuring that all correspondence with clients is professional and appropriate by adherence to process guidelines.

Skills on Resume:

• Claims Adjudication (Hard Skills)
• Payment Verification (Hard Skills)
• Customer Communication (Soft Skills)
• Independent Judgment (Soft Skills)
• Technical Verification (Hard Skills)
• Data Clarification (Hard Skills)
• Financial Settlement (Hard Skills)
• Team Collaboration (Soft Skills)

Job Summary:

• Perform various duties with a high degree of accuracy. 
• Evaluate claims to determine eligibility for benefits by the policy contract. 
• Independent action and judgment decisions
• Responsible for processing claims according to Company procedures and performing necessary accounting entries required to complete claims processing. 
• May require direct contact with policyholders, PR Representatives, Marketing Specialists, claimants, agents and/or medical providers regarding claims process. 
• Contact is by telephone, e-mail and written correspondence. 
• Accurately adjudicate professional claims by external regulations, internal production standards and contractual obligations in a managed care setting.
• Experience with claims adjudication in a managed care setting on the payer side. 
• Process fee for service commercial and/or senior plan claims.
• Process routine and complex electronic and paper medical claims (HCFA 1500, UB04) within the claims system, by plan provisions
• Ensure correct data entry, correct provider coding information and appropriateness of reported services
• Communication and collaboration with all members of the SCAN team through knowledge and idea-sharing
• Follow and understand HIPAA regulations

Skills on Resume:

• Claims Evaluation (Hard Skills)
• Independent Decision-Making (Soft Skills)
• Claims Processing (Hard Skills)
• Stakeholder Communication (Soft Skills)
• Claims Adjudication (Hard Skills)
• Data Entry Accuracy (Hard Skills)
• Team Collaboration (Soft Skills)
• HIPAA Compliance (Hard Skills)

Job Summary:

• Review and evaluate claims for appropriate coding against charges that are being billed.
• Determine the level of reimbursement based on established criteria, provider contracts, or plan provisions.
• Generate appropriate member and provider denials based on established departmental guidelines and training. 
• Ensure corresponding denial letters are accurate.
• Identify and report adjudication inaccuracies that are related to system configuration, benefit inconsistencies, and fee schedules.
• Consistently meet individual performance metrics to ensure department quality and productivity standards are met.
• Work assigned cases through SCANs workflow system, apply correct status attributes to track and trend issues. 
• Notate cases with required detail to ensure that others understand the status of the case and final resolution.
• Identify and report problems with workflows following proper departmental procedures
• Actively participate in departmental staff meetings and training sessions.
• Provide a high level of customer service to members, providers, and internal customers by consistently meeting and/or exceeding team expectations including productivity and attendance.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.

Skills on Resume:

• Coding Evaluation (Hard Skills)
• Reimbursement Determination (Hard Skills)
• Denial Generation (Hard Skills)
• Performance Metrics (Hard Skills)
• Workflow Management (Hard Skills)
• Detailed Notation (Hard Skills)
• Customer Service (Soft Skills)
• Regulatory Compliance (Hard Skills)