[Hiring] Insurance Claims Processor @WVU Medicine

Role Description

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, evaluates online entry, error correction, and quality control for final adjudication of paper/electronic claims.

Qualifications

• High School diploma/GED
• One (1) year of experience working with medical or institutional claim data entry OR customer service experience.
• Associate Degree in related healthcare field (preferred).
• Two plus years of medical or institutional claims processing and customer service experience (preferred).

Requirements

• Determines accuracy and completions of claim information. Entry/verifies claims data.
• Resolves claim edits, reviews history records, and determines benefit eligibility for service.
• Reviews payment levels to arrive at final payment determination.
• Meets all production and quality standards, maintaining work queues according to department standards.
• Effectively communicates with internal and external staff.
• Elevates issues to next level of supervision, as appropriate.
• Ensures accuracy of data entered and record maintenance.
• Attends all required training classes, demonstrating proficiency and ability to learn.
• Other duties as deemed appropriate by the Claims Manager.

Physical Requirements

• Ability to sit for extended periods of time.

Working Environment

• Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.).
• Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access), Internet Explorer, and EPIC.

Skills and Abilities

• Working knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
• Ability to take direction and to navigate through multiple systems simultaneously.
• Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette.
• Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.
• Ability to use mathematics to adjudicate claims.
• Requires the ability to understand medical insurance requirements for payment and basic knowledge of covered services.
• Knowledge and understanding of medical terminology, third party payors, and insurance preferred.
• Requires attention to detail, the ability to be organized, and to be able to perform multiple tasks simultaneously.

Additional Job Description

• Scheduled Weekly Hours: 40
• Shift: Day (United States of America)
• Exempt/Non-Exempt: United States of America (Non-Exempt)
• Company: PHH Peak Health Holdings
• Cost Center: 2902 PHH Claims Operations