Gateway Health Plan
Job Description :
Screens, reviews, evaluate online entry, error correction and / or quality control review and final adjudication of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. May include initial entry claims or claims which have suspended. Translate foreign language claims into English using software and code appropriately. Convert foreign currency to US dollar and code charges appropriately. Reviews processed claims and inquiries to determine corrective action which can include adjusting claims. Takes the corrective action steps using enrollment, benefit and historical claim processing information.
Essential Job Functions:
1. Determine if claim information is complete and correct. Enter/verify claims data.
2. Resolve claim edits, review history records and determine benefit eligibility for service. Review payment levels to arrive at final payment determination.
3. Meets all production and quality standards. Attends all required training classes.
4. Elevates issues to next level of supervision, as appropriate.
5. Maintains accurate records, including timekeeping records.
6. Other duties as assigned or requested.
- High School Diploma/GED required for all levels
- 1-3 years of Claims Processing experience
- Typing speed of at least 60 words per minute
Knowledge, Skills & Abilities:
- Ability to take direction and to navigate through multiple systems simultaneously.
- Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
- Ability to use mathematics to adjudicate claims.
- Ability to solve problems within pre-defined methods and guidelines.
- Knowledge of operating systems specific to claim processing.
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.
EEO is The Law
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