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Claims Processor I

Company: TalentBoost (Point32Health)
Location: North Billerica
Posted on: November 26, 2022

Job Description:

The Claims Processor I is responsible for the timely and accurate processing of Point32Health claim inventory as assigned by the Claims Supervisor. Using basic analytical and problem-solving skills, the Claims Processor I is expected to fully examine and resolve all problem codes initially assigned to each claim. -Key Responsibilities/Duties - what you will be doingProcess claims as assigned by supervisor:

  • Examine claim to correct and/or update data so claim can properly adjudicate.
    • Ensure claim payment is updated to correctly reflect Point32Health's status as primary or secondary payer through the appropriate coordination of benefits.
    • Determine member's eligibility if in question.
    • Check to determine if services rendered on the claim are allowable under the members benefit plan and/or the proper authorization, referrals and pre-registrations were obtained as required by the plan.
    • Communicate with partner departments (verbally and/or written) to obtain missing information to properly adjudicate claims, such as provider numbers, authorizations and referrals.
    • Manually calculate and/or apply pricing to each claim when necessary.Quality & Production:
      • Achieve individual standards for quality and production as required by CMS.
      • Contribute to team and departmental standards for quality and production.
      • Monitor pending claims daily and ensure claims are released timely for adjudication.
      • Participate in identifying opportunities for overall process improvementsOther:
        • Participate in initiatives or provide back up support to other areas of department as requested.
        • Participate in staff & individual meetings and training sessions as required.
        • Comply with all department and company guidelines and policies. -Qualifications - what you need to perform the jobEDUCATION: Associates degree or equivalent business experience in a claims/customer service healthcare environment preferred.EXPERIENCE: 12-18 months experience in a Point32health claims /customer service position or similar claims processing experience requiredSKILL REQUIREMENTS: Experience with Point32Health's internal applications, such as Diamond, Macess, and HealthEdge preferred. Understanding of managed care concepts and a strong understanding of CPT, ICD-10), HCPCS coding guidelines and CMS1500 & UB04 billing forms preferred. Position requires basic problem solving and analytical skills with the ability to multi-task. Must be able to work independently and as a part of a team. Ability to effectively communicate to partner departments. Working knowledge of Microsoft Office applications and internet navigation is preferred. -WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: Overtime may be required during peak volume periods as requested by management. Requires ability to use personal computer, sitting for extended periods of time. -CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times. -Commitment to Diversity, Equity & InclusionPoint32Health is committed to making diversity, equity, and inclusion part of everything we do-from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. -COVID PolicyPlease note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law. -About the CompanyPoint32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.We enjoy the important work we do every day in service to our members, partners, colleagues and communities.This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.Req ID: R5329

Keywords: TalentBoost (Point32Health), Boston , Claims Processor I, Other , North Billerica, Massachusetts

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