Claims Adjudicator at BMC HealthNet Plan in Boston, Massachusetts

Job Description:

Claims Adjudicator

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Responsible for the accurate and timely processing of claims. Must meet published quality and productivity standards. Also, responsible for simple adjustments to previously processed claims.

Key Functions/Responsibilities:

• Evaluates and processes claims in accordance with company policies and procedures according to productivity and quality standards.


• Interprets and processes routine and less complex claims including CMS 1500 and UB04.


• Reviews and analyzes data from system-generated reports for in-process claims in order to identify and resolve errors prior to final adjudication.


• Alerts claims management to claims aging issues as well as provider billing problems.


• Maintains current knowledge of BMCHP members' benefits, policies/procedures, provider network development and contract issues, processing system issues, Massachusetts Medicaid regulations, as well as industry standards for claims adjudication.


• Consistently maintains production standards based on transactions/units per hour


• Consistently meets quality standards

Qualifications:

Education:

• High School degree or equivalent required.


• Associate degree or some college coursework preferred.

Experience:

• Two years or more years experience in managed care claims processing preferred.

Competencies, Skills, and Attributes:

• Working knowledge of medical terminology as well as CPT4, HCPCS and ICD9 coding sets and HIPAA regulations.


• Knowledge of Microsoft Office and FACETS preferred.


• Ability to maintain production level and quality goals.


• Follow through on commitments and meets deadlines


• Work is thorough, accurate, and effective.


• Demonstrates ability to complete assigned work in a timely fashion.

Working Conditions and Physical Effort:

• Ability to work OT during peak periods.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.