[Hiring] Claims Adjudicator II @UNITE HERE HEALTH

Role Description

The Claims Adjudicator II position will receive, examine, verify and input submitted medical claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries.

• Screens claims for completeness of necessary information
• Verifies participant/dependent eligibility
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
• Codes basic information and selects codes to determine payment liability amount
• Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
• Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
• Handles the end to end process of Medicare Secondary Payer (MSP) files
• Processes Personal Injury Protection (PIP) claims
• Requests overpayment refunds, maintains corresponding files and performs follow-up actions
• Handles verbal and written inquiries received from internal and external customers
• Processes Short Term Disability claims
• Adjudicates claims according to established productivity and quality goals
• Achieve individual established goals in order to meet or exceed departmental metrics

Qualifications

• 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment
• Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation and its related processes
• Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes
• Fluency (speak and write) in Spanish, preferred

Requirements

• Hourly salary range: $20.36 - $24.97
• Actual base salary may vary based upon relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.
• Work Schedule: Monday~Friday, 7.5 hours per day (37.5 hours per week) Fully Remote, after 1-week training onsite in Oak Brook, IL. (Travel and Lodging paid for by UHH)

Benefits

• Medical
• Dental
• Vision
• Paid Time-Off (PTO)
• Paid Holidays
• 401(k)
• Pension
• Short- & Long-term Disability
• Life, AD&D
• Flexible Spending Accounts (healthcare & dependent care)
• Commuter Transit
• Tuition Assistance
• Employee Assistance Program (EAP)