Excess Risk Claim Unit Assistant

Company :

HM Insurance Group

Job Description : 

GENERAL OVERVIEW

Acting in the role of Excess Risk Claim Unit Assistant, this position is responsible for Evaluating specific Stop Loss notice and/or claim information for potentially catastrophic and/or existing catastrophic claims, identifying potential enhancements to applications and/or processes to improve efficiency, communicating effectively with clinical staff, claim staff and department management and promoting a culture of performance excellence departmentally.

ESSENTIAL RESPONSIBILITIES

• Evaluating Specific Stop Loss notice and/or claim information for potentially catastrophic and/or existing catastrophic claims.
  • Evaluate each notice and/or claim and execute the appropriate business rules for triaging notice of potential claim data to clinicians and/or actual claim data to the claim analysts.
  • Create the appropriate system entries (notice or claim payment request) based on the information evaluated.

• Identifying potential enhancements to applications and/or processes to improve efficiency
  • Make recommendations to management, as appropriate, for application changes to improve efficiency.
  • Communicate with management regarding process improvement opportunities to improve efficiency.

• Communicating effectively with clinical staff, claim staff and department management.  •    
  • Identify and articulate problems/issues to various staff members, including all levels of department management.
  • Participate in functional walk-throughs as requested and provide feedback.

• Promoting a culture of performance excellence departmentally
  • Enhancing job skills through training and participation in workshops
  • Participating in process and operational improvement opportunities
  • Building and maintaining effective relationships throughout the department to build performance excellence.

• Other duties as assigned or requested.

QUALIFICATIONS
Minimum

• High School Diploma/GED
• Minimum 3 years’ experience in claim administration activities
• Working knowledge of ICD, HCPC, CPT4 coding and medical terminology    

Preferred

• Prior experience with specific stop loss claims and/or notices of potential claims
• Strong medical policy background
• Prior experience with researching medical claim data

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly 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

Yes

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.

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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