Claims Adjuster Blue Card-3 OPEIU

Company :

Job Description : 

JOB SUMMARY

Provides customers with complete, accurate and timely claims review and performs adjustments of claims relative to Blue Card claims administration and claims related tasks.

This is a bargaining unit position. The collective bargaining agreement for this position requires that candidates and employees reside in the following counties in the State of New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, or Wyoming.

ESSENTIAL RESPONSIBILITIES

• Adjusts Blue Card claims under provisions of applicable contracts, provider operating agreements and corporate procedures through the performing of on-line transactions and /or adjustments utilizing the corporate claims administration system.  Identifies potential fraudulent cases and forwards to Special Investigations Department for further review. Identifies opportunities to resolve issues on behalf of the customer, through process improvement requests. Provides necessary documentation to management for recommendations on changes in departmental procedures/desk levels. 

• Initiates correspondence and/or telephone contact incidental to general claims administration/adjustments and/or assignments.  Answers written and/or verbal inquires/correspondence from internal and/or external customers.

• Maintains accurate daily production records as needed.

• Maintains confidentiality and adheres to HIPAA regulations.

• Delivers service to internal and/or external customers in a professional, polite and efficient manner.

• Performs all job duties efficiently and at an acceptable rate of performance.

• Other duties as assigned or requested.

EXPERIENCE

Required

• Healthcare or insurance related experience; claims processing experience; knowledge of medical terminology.

Preferred

• Previous claims processing or equivalent experience.

SKILLS

• Must meet minimum qualifications to perform the job including satisfactory completion of all training and testing, inlcduing Basic Computer Literacy test, Typing Skills: 30WPM, and Job Content test.

• Ability to multitask if fast paced environment.

• Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills.

• Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner

• Ability to utilize basic office equipment.

• Problem Solving.  Identified issues and problems; identifies opportunities for improved claims processing.

EDUCATION

Required

• High School/GED

Preferred

• None

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office- or Remote-based

Teaches / trains others

Occasionally

Travel from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Rate:

The starting hourly rate for this position listed above is for new employees. This rate has been established by the Local 153, Office and Professional Employee International Union (OPEIU) collective bargaining agreement (CBA) and is non-negotiable. If the successful candidate is currently a bargaining unit member of the OPEIU, hourly rate is commensurate with their anniversary year and pay grade as per the CBA.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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