保险理赔处理员
Insurance Claims Processor
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此职位将向理赔经理汇报，将在我们改善医疗保健的使命中发挥独特而重要的作用。在医疗行业的工作经验和批判性思维能力将有助于组织建立高效、有效的理赔团队。理赔团队将审查和监督从简单的数据录入到复杂的专科理赔研究的各种理赔。理赔团队将分析和处理保险理赔，检查其有效性。必须能够根据组织的政策和程序决定是否退回、拒付或支付理赔。此工作负责在线录入的筛查、审查、错误更正和质量控制，以最终裁定纸质/电子理赔。
最低资格要求：
教育、认证和/或执照：
1. 高中文凭/GED
经验：
1. 一年医疗或机构理赔数据录入经验 或 一年客户服务经验。
优先资格要求：
教育、认证和/或执照：
1. 相关医疗领域的副学士学位。
经验：
1. 两年以上医疗或机构理赔处理和客户服务经验。
核心职责和责任：此处描述的陈述旨在描述分配到此职位的人员所从事工作的总体性质。它们不构成所有职责和职责的详尽列表。可能会分配其他职责。
1. 确定理赔信息的准确性和完整性。录入/验证理赔数据。
2. 解决理赔编辑问题，审查历史记录，并确定服务的福利资格。
3. 审核付款级别以确定最终付款决定。
4. 满足所有生产与质量标准，按照部门标准保持工作队列。
5. 与内部和外部员工有效沟通。
6. 在适当的情况下将问题上报给上级主管。
7. 确保录入数据的准确性及记录维护。
8. 参加所有必要的培训课程，展示熟练程度和学习能力。
9. 其他由理赔经理认为适当的职责。
查看英文原文
Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.
This position will report to the Claims Manager, playing a unique and important role in our mission to change healthcare for the better. Experience in the healthcare industry and critical thinking skills will help the organization build an effective and efficient claims team. The claims team will review and oversee the adjudication of claims ranging from the simple data entry to complex specialty claim research. The Claims Team will analyze and process insurance claims, checking for validity. Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures is a must. This job screens, reviews, evaluate online entry, error correction, and quality control for final adjudication of paper/electronic claims.MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. High School diploma/GED
EXPERIENCE:
1. One (1) year of experience working with medical or institutional claim data entry OR One (1) year of customer service experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Associate Degree in related healthcare field.
EXPERIENCE:
1. Two plus years of medical or institutional claims processing and customer service experience.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Determines accuracy and completions of claim information. Entry/verifies claims data.
2. Resolves claim edits, review history records, and determine benefit eligibility for service.
3. Reviews payment levels to arrive at final payment determination.
4. Meets all production and quality standards, maintaining workques according to department standards.
5. Effectively communicates with internal and external staff.
6. Elevates issues to next level of supervision, as appropriate.
7. Ensures accuracy of data entered and record maintenance.
8. Attends all required training classes, demonstrating proficiency and ability to learn.
9. Other duties as deemed appropriate by the Claims Manager.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Ability to sit for extended periods of time.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)
2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access) Internet Explorer and EPIC
SKILLS AND ABILITIES:
1. Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
2. Ability to take direction and to navigate through multiple systems simultaneously.
3. Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette
4. Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.
5. Ability to use mathematics to adjudicate claims
6. Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services.
7. Knowledge and understanding of medical terminology, third party payors and insurance preferred.
8. Requires attention to detail, the ability to be organized and to be able to perform multiple tasks simultaneously.
Additional Job Description:
Scheduled Weekly Hours:
40Shift:
Day (United States of America)Exempt/Non-Exempt:
United States of America (Non-Exempt)Company:
PHH Peak Health HoldingsCost Center:
2902 PHH Claims OperationsOriginally posted on Himalayas