Adjudicator Job Description Sample
Claims Adjudicator Division: Shared Services Department:
Managed Care Finance Schedule: Full-Time Shift: AM/PM Hours: Job Details:
Job Summary: This position will support LLUSS's strategic plan and the organization's mission to continue the teaching and healing ministry of Jesus Christ, while embracing the core values of Compassion, Integrity, Excellence, Teamwork, and Wholeness.
Reports to the Director-Managed Care Finance. The Claims Adjudicator is responsible for analyzing and processing Hospital Risk claims in accordance with the managed care contract provisions in an accurate and timely manner. Responds to questions from other adjudicators and processors.
Verifies system assigned risk pool determination in accordance with the Division of Financial Responsibility matrix. Assists Director in creating, reviewing, and enhancing policies and procedures governing full risk claims processing on an annual basis or as needed. Assists other adjudicators and/or examiners as needed in order to assure that claims are completed within standards.
Performs other duties as needed. Job Specifications: Extensive experience in health insurance claims processing, HMO claims or managed care environment is preferred, in-depth knowledge of medical billing and coding, knowledge of health insurance, HMO and managed care principles.
Claims Payment System including Claim Hierarchy Categories, CPT, ICD-10, HCPCS, UB-04. Able to read; write legibly; speak in English with professional quality; use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate/troubleshoot basic office equipment required for the position; Able to relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision.
Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position. Associate's Degree in health or business field required. Minimum five years of experience in claims adjudication required.
Valid California Driver's License required. EOE AA M/F/Vet/Disability
Sr. Claims Adjudicator
Looking for a way to influence the health and healthcare of many? If so, we’d love to hear from you! Our mission-driven organization is focused on the“Triple Aim” - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans. UNITE HERE HEALTH serves 90,000+ workers in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity! Key Attributes:
Integrity – Must be trustworthy and principled when faced with complex situations
Ability to build positive work relationships – Mutual trust and respect will be essential to the collaborative relationships required
Communication – Ability to generate concise, compelling, objective and data-driven reports
Teamwork – Working well with others is required in the Fund’s collaborative environment
Diversity – Must be capable of working in a culturally diverse environment
Continuous Learning – Must be open to learning and skill development. As the Fund’s needs evolve, must be proactive about developing new areas of expertise
Lives our values – Must be a role model for the Fund’s BETTER Culture and Mission (Better, Engage, Teamwork, Trust, Empower, Respect) The purpose of this position is to receive, examine, verify and input submitted claims data, determine eligibility status, review and adjudicate claims within established timeframes, and assists less experienced staff members to resolve claim questions. In addition to performing the day to day job functions of claim analysis and payment, the Sr. Claims Adjudicator may have responsibility for specified quality assurance functions, training, adjustments, certain defined medical necessity, benefit or coverage applications and other administrative duties as determined by claims department management.
Screen claims for completeness of necessary information
Verify participant/dependent eligibility.
Interpret the applicability of benefits from the SPD/Plan Documents
Code basic information and select codes to determine payment liability amount
Based on established guidelines, evaluate diagnoses, procedures, services, and other submitted data to determine if additional investigation or proof is required from participants, employers, providers and other insurance carriers
Apply knowledge and decide applicability of benefits, frequency limitations or appropriateness of care rendered and determine the validity of proof of loss documentation
Research claims, initiate corrections, update history and refer claims to appropriate personnel
Request overpayment refunds, maintain corresponding files and perform follow-up actions
Maintain related claim adjudication manuals, SPD’s, memos and reference material updates
Meet or exceed established productivity and quality goals
Monitor inventory aging to select and process claims within established time frames and process assigned claims on a first-in, first-out basis, regardless of complexity/ difficulty
Process claim adjustments and or assist with finalization of difficult adjustments as required or directed that are beyond the ability or experience of claim analysts
Resolve Customer Service Inquiries on a timely basis, including difficult cases beyond the experience or ability of other claim analysts
Perform first level quality review of high dollar claims processed by claim analysts
Research, validate and respond to system related questions/issues from claim analysts
Assist with training and preparation of training materials for claim staff
Perform routine administrative functions as assigned
Function as willing “go to” first level claim resource and answer person for less experienced or trained staff
Perform other duties as assigned within the scope of responsibilities and requirements of the job
High School Diploma
College coursework a plus
Technical training in the area of medical terminology, ICD9 and CPT codes is a plus
Minimum of 2 years experience in a claims adjudication an automated environment
Experience utilizing a claims payment system e.g., RIMS, strongly preferred
Experience with and understanding of medical terminology, ICD9 and CPT coding usage
The candidate must demonstrate a continuing example of high production levels and excellent financial and procedural accuracy.
The position demands that the candidate maintain multiple claim type processing expertise and demonstrated ability to manage and effectively prioritize a variety of assignments, projects and administrative functions.
Work experience should include interpretation of medical benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
Experience with eligibility verification, medical coding, coordination of benefits and subrogation Ability to:
Make appropriate decisions related to benefits and coverage applications within defined area of responsibility
Be able and willing to work well with other staff members as a leader in a team oriented structure
Manage competing deadlines and multiple projects in a fast-paced environment
Perform the essential functions of this job with or without reasonable accommodation ID: 2018-1410 Organization: UNITE HERE HEALTH External Company URL: https://www.uniteherehealth.org
World Services Corporation is seeking talented individuals committed to excellence, honesty, and integrity to join our team. We are a trusted provider of high-quality background investigations programs to Department of Homeland Security (DHS) and the intelligence community at locations throughout the United States. If you have investigations experience,
OMNIPLEX is where you want to be for the future.
Geographic Location: Woodlawn, Maryland
Bachelor’s degree or equivalent combination of education and experience;
Must have two (2) year of experience performing adjudciations; five (5) years of adjudicative experience preferred
Must have three (3) years of experience within Personnel Security
High oral communication skills including the ability to interact effectively with individuals at all levels of the employer’s and/or customer’s organization;
High reasoning skills, including the ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in oral, written, diagram, or schedule form.
High language skills, including the ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to present information in an effective manner to senior management.
Intermediate math skills, including the ability to calculate figures and amounts.
High computer skills and ability to work in MS Windows based operating environment, including proficiency with Microsoft Office (Word, Excel, PowerPoint), Internet and E-mail.
Must be U.S. citizen and able to successfully undergo background investigation to obtain U.S. Government security clearance.
Essential Duties and
Monitor, track, review, analyze, adjudicate, and compile results of completed BI’s of government personnel and contract employees conducted by OPM, FBI, and other Federal investigative agencies and provide a recommendation for approval, disapproval, or referral for further investigation.
Evaluate favorable and derogatory information, issue Letters of Interrogatory to resolve outstanding issues, prepare a written report of findings and recommend the appropriate suitability/security determination.
Assists with updating BI policies and procedures as requested.
OMNIPLEX is committed to a drug-free workplace. As such, the Company conducts pre-employment, reasonable cause, random and contract-mandated testing in accordance with federal and state law. EOE Minority/Female/Disabled/Veteran
Job Description The Adjudicator I performs background investigation review, individualized assessments (which may include interviews of prospective and current employees), and adjudication recommendations. All activities are performed with a high degree of confidentiality and professionalism.
The Adjudicator I must be organized, maintain a high level of documentation accuracy, and have the ability to work within established timelines and service level agreements to ensure efficiency and a positive experience for impacted individuals, both internal and external. The Adjudicator I must beknowledgeable of applicable laws related to background investigations andconsumer reporting, including but not limited to the Fair Credit ReportingAct and EEOC Guidance related to the “Consideration of Arrest and
Conviction Records in Employment Decisions”. The Adjudicator I must alsounderstand, contribute to, and comply with internal process documentationand policy in order to mitigate risk, ensure compliance, and protectcompany assets. Essential
Duties & Responsibilities:
- Review completed background investigations including social securitynumber verification alerts; federal, state, and county court information;sex offender, child abuse, and other registry findings; and motor vehiclerecords
Conduct individualized assessments in accordance with companypolicy, which may include conducting interviews with prospective andcurrent employees related to additional details about the backgroundinvestigation findings
Document all evaluation and interview notes
Evaluate the details of the background investigation, interviewnotes, and all other documentation and deliver an adjudicationrecommendation
Comply with all policies and procedures
Conduct all activities with a high level of accuracy andconfidentiality, while maintaining service levels, and delivering aseamless service experience
Assist with updating policies and procedures as requested
Required Qualifications 5 years of experience with corporate background investigation programs,compliance or Human Resources
Preferred Qualifications -5 years of experience with corporate background investigation programs,compliance or Human Resources
Proficient with Microsoft tools, including Excel for the purpose of analyzing and presenting data and metrics
Excellent communication skills, interpersonal and written
Education Associates Degree or equivalent number of years of experience
Business Overview CVS Health, through our unmatched breadth of service offerings, is transforming the delivery of health care services in the U.S. We are an innovative, fast-growing company guided by values that focus on teamwork, integrity and respect for our colleagues and customers.
What are we looking for in our colleagues? We seek fresh ideas, new perspectives, a diversity of experiences, and a dedication to service that will help us better meet the needs of the many people and businesses that rely on us each day. As the nation’s largest pharmacy health care provider, we offer a wide range of exciting and fulfilling career opportunities across our three business units – MinuteClinic, pharmacy benefit management (PBM) and retail pharmacy.
Our energetic and service-oriented colleagues work hard every day to make a positive difference in the lives of our customers. CVS Health is an equal opportunity employer. We do not discriminate in hiring or employment against any individual on the basis of race, ethnicity, ancestry, color, religion, sex/gender (including pregnancy), national origin, sexual orientation, gender identity or expression, physical or mental disability, medical condition, age, veteran status, military status, marital status, genetic information, citizenship status, unemployment status, political affiliation, or on any other basis or characteristic prohibited by applicable federal, state or local law.
CVS Health will consider qualified job candidates with criminal histories in a manner consistent with federal, state and local laws. CVS Health will not discharge or in any other manner discriminate against any Colleague or applicant for employment because such Colleague or applicant has inquired about, discussed, or disclosed the compensation of the Colleague or applicant or another Colleague or applicant. Furthermore, we comply with the laws and regulations set forth in the following EEO is the Law Poster:
EEO IS THE LAW at https://www.dol.gov/ofccp/regs/compliance/posters/pdf/eeopost.pdf and EEO IS THE LAW SUPPLEMENT at https://www.dol.gov/ofccp/regs/compliance/posters/ofccpost.htm Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. If you require assistance to apply for this job, please contact us by clicking EEO AA CVS Health at mailto:EEO_AA@CVSHealth.com CVS Health does not require nor expect that applicants disclose their compensation history during the application, interview, and hiring process. For inquiries related to the application process or technical issues please contact the Kenexa Helpdesk at 1-855-338-5609.
For technical issues with the Virtual Job Tryout assessment, contact the Shaker Help Desk at 1-877-987-5352. Please note that we only accept resumes via our corporate website: https://jobs.cvshealth.com/
Mercer is a global consulting leader in talent, health, retirement and investments. Mercer helps clients around the world advance the health, wealth and performance of their most vital asset - their people.
Mercer's 20,000 employees are based in more than 40 countries. If you thrive on challenge, are passionate about ideas, love solving problems and truly enjoy connecting with people, we encourage you to explore the hundreds of job opportunities available through Mercer. Our core strengths place Mercer in a unique position to help our clients achieve the extraordinary - and extraordinary results require extraordinary people.
Mercer is a wholly owned subsidiary of Marsh & McLennan Companies (NYSE: MMC), a global team of professional services companies offering clients advice and solutions in the areas of risk, strategy and human capital.The purpose of this position is to process basic claims and correspond with insured and providers in a prompt, informative, and courteous way. The incumbent in this role also interacts with other departments in order to obtain information needed to process claims. The position works within established procedures applying basic understanding of a body of knowledge.
Reviews claim requests to determine eligibility for processing and escalate to management as necessary.
Makes appropriate system entries and verifies accuracy.
Ensures utilization of most up to
Claims Adjudicator II
It’s Time For A Change… Your Future Evolves Here Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans. Are we growing? Absolutely—56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it. What You’ll Be Doing: We are looking for an experienced individual to fill our Claims Adjudicator II team position. The successful candidate will have at minimum 3-5 years of experience adjudicating claims in a Claims Center environment. They will use their proven strong analytical skills to review claim rules and workflows. Additional essential functions would also be:
Experienced level adjudicator providing analytical ability to review claim rules and workflows
Responsible for adjudicating claims to maintain/comply with Service Level Agreements
Determine accurate payment criteria for clearing pending claims based on defined Policy and Procedures
Ability to understand logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.)
Research CMS1500 claim edits to determine appropriate benefit application utilizing established criteria
Apply physician contract pricing as needed
Ability to resolve claims that require adjustments and adjustment projects
Identify claim(s) with inaccurate data or claims that require review by appropriate team members
Maintain productivity goals, quality standards and aging timeframes
Contribute positively as a team player
Complete special projects as assigned
Comply with all departmental and company Policy and Procedures The Experience You’ll Need (Required):
Associate or Bachelor degree preferred.
Experience in health insurance claims processing with a minimum of 3 to 5 years adjudication experience.
HMO Claims or managed care environment preferred.
Ability to work in a team environment
Integrity and discretion to maintain confidentiality of members, employee and physician data
Knowledge of medical billing and coding
Knowledge of health insurance, HMO and managed care principles
Critical thinking skills and analytical ability to work, discover and outline systems related issues independently and within a team to provide resolution to work products
Attention to detail
Excellent interpersonal, oral and written communication skills
Strong attention to detail and organization
Able to work independently; strong analytic skills
Strong computer skills Evolent Health is an Equal Opportunity/Affirmative Action Employer
This position will support LLUSS's strategic plan and the organization's mission to continue the teaching and healing ministry of Jesus Christ, while embracing the core values of Compassion, Integrity, Excellence, Teamwork, and Wholeness. Reports to the Director-Managed Care Finance.
The Claims Adjudicator is responsible for analyzing and processing Hospital Risk claims in accordance with the managed care contract provisions in an accurate and timely manner. Responds to questions from other adjudicators and processors. Verifies system assigned risk pool determination in accordance with the Division of Financial Responsibility matrix.
Assists Director in creating, reviewing, and enhancing policies and procedures governing full risk claims processing on an annual basis or as needed. Assists other adjudicators and/or examiners as needed in order to assure that claims are completed within standards. Performs other duties as needed.
Job Specifications:Extensive experience in health insurance claims processing, HMO claims or managed care environment is preferred, in-depth knowledge of medical billing and coding, knowledge of health insurance, HMO and managed care principles. Claims Payment System including Claim Hierarchy Categories, CPT, ICD-10, HCPCS, UB-04.
Able to read; write legibly; speak in English with professional quality; use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate/troubleshoot basic office equipment required for the position; Able to relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position. _Associate's Degree in health or business field required.
Minimum five years of experience in claims adjudication required. Valid California Driver's License required. __ _ EOE AA M/F/Vet/Disability
Division:* Shared Services
Department:* Managed Care Finance
Medical Claim Adjudicator
Medical Claim Adjudicator Medical Claim Adjudicator
Long Term Care Claims, Claimant Eligibility, Policy Coverage, Benefit Qualifying, Medical Terminology, Disability Claims
As the Medical Claim Adjudicator, candidate will handle a variety of Long Term Care (LTC) and/or Disability Claims in a fast paced office setting including: utilizing claim policies and guidelines, reviewing policy coverage and qualifying providers, determining claimant eligibility, communicating with and educating policyholders and providers on benefits, and negotiating alternative care benefits as applicable.
The Case Manager 1 will directly manage a daily caseload of claims and may be required to present claim facts during department claim discussions.
Awesome opportunity for a new RN or LPN!
What You Will Be Doing
Determines eligibility of LTC claims to individualized policy
Uses claims guidelines and policy language to interpret LTC policy coverage to determine eligibility
Evaluates provider qualification and covered services
Inputs accurate and complete data, information, and notes into the claims administrative system to document eligibility
Monitors aging of assigned tasks to ensure established turnaround time standards are met
Educates claimants and their representatives on policy coverage and claim processes
Serves as point of contact for claimants and/or their representatives ensuring a positive experience
Participates in process improvements by assisting with development of improved customer service strategies
Keeps current on state/territory regulations and issues as well as industry activities and trends
Investigates and analyzes medical evidence to determine whether policy benefit qualifier(s) are met
Consults with claimants physician and/or providers as required
Performs telephonic evaluation of claimant to track progress and determine if care needs change over time
Identifies claims for escalation and special handling including proposed denials, fraud, and coordination of benefits with other payer sources
What You Need for this Position
Bachelors degree or equivalent experience
Minimum of 2 to 5 years insurance claims experience, LTC, disability, or related healthcare claims
Professional designations, RN/LPN a plus, however, not mandatory
Proven knowledge of claims and/or LTC insurance industry and practices
Understanding of medical terminology
Excellent verbal, written and presentation skills to communicate effectively
Strong analytical and problem solving skills with ability to manage and prioritize multiple claims, and assigned projects
Ability to exercise independent judgment and make critical business decisions which effectively support the merits of claims
Solid knowledge of Microsoft Office Products as well as other business-related software
Ability to learn new system applications quickly and adapt to change easily
For your hard work and dedication, earn a generous salary plus comprehensive benefit package including 401k with 5% match, tuition reimbursement and much more! This is a tiered opportunity w/possible increase in 12 months!
Applicants must be authorized to work in the U.S.
CyberCoders, Inc is proud to be an Equal Opportunity Employer
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status, or any other characteristic protected by law.
Your Right to Work ? In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.
Medical Claim Adjudicator
Immediate Opening for a Claims Adjudicator. Apply Now! Robert Half Healthcare Practice is looking for a Claims Adjudicator for a well-known client on the East Bay. This role will be responsible for:
Claims pre-processing, matching, batching, coding, and entering invoices
Posting and reconciling batches
Examine and enter basic claims for appropriateness of care
Process claims for multiple plans
Req ID: 00343-9500870160 Functional Role: Administrative - Medical
Postal Code:* 94612 Compensation: $1.00 to $1.00 per hour
* * 5+ years' experience
Knowledgeable in Medical coding (including CPT4, HCPCs, ICD-9) with EMR experience
Proficient in the operation of MS Office Suite
Familiar with all types of insurance carriers
Knowledgeable in Medical Terminology, ICD-10, CPT, HCPCS, ASA, and UB92codes and standard of billing guidelines required
Entering basic claims
Approving, denying, or pending payment according to plan
Adjudicator -Full Performance
Provide adjudicative support services to assist in meeting the mission requirements of customers throughout the organization. Requires full performance knowledge and experience of Federal-level adjudicative processes. Security Analyst Assistants at the Full Performance level shall provide a diverse range of adjudicative functions to include but not limited to:
review case files to determine needed security processing actions
create written products documenting case processing
advise the customer of the need for additional security processing to render an adjudicative decision
review results of all security processing relevant to the final adjudicative recommendation
conduct interviews of candidates in person, via telephone or through written correspondence
discuss and present cases to supervisors and subject matter experts as needed
provide a final written recommendation with sufficient detail to permit the sponsor to make an informed decision to regarding security clearance approval or denial
perform file maintenance to include removing duplicate copies of documents, unofficial notes, etc
responds to status inquiries in a timely manner • meets quality standards established by the customer
- manages case load effectively to meet productivity standards established by the customer
Must be a US citizen possessing TS/SCI clearance with a polygraph at time of application.
Minimum three years Adjudicative experience at the Federal level or extensive analyst experience; investigative experience is desired by not required.
High School diploma or GED.
Must possess demonstrated analytical ability and the ability to handle a large complex workload
Must demonstrate a high level of personal integrity and the ability to discreetly handle sensitive, personal and classified case information
Must have excellent writing skills with ability to comprehend complex and multi-source data into succinct and supportable final reports
Must possess strong organizational skills and good judgment
Must be able to operate various corporate and customer specific automated systems for case tracking and status reporting
Must have a thorough understanding of the federal rules and regulations that encompass the clearance process
Demonstrated ability to produce analytic documents that require minimal editing, utilize software tools (MS Word/Excel/Power Point)
Ability and skill to elicit information during an interview with minimal direction and work effectively with a variety of individuals
Ability to provide excellent customer service
Ability to work well with various client personnel and stakeholders
Strong briefing and presentation skills An Equal Opportunity Employer. PAE’s hiring practices provide equal opportunity for employment without regard to race, religion, color, sex, gender, national origin, age, United States military veteran’s status, ancestry, sexual orientation, marital status, family structure, medical condition including genetic characteristics or information, veteran status, or mental or physical disability so long as the essential functions of the job can be performed with or without reasonable accommodation, or any other protected category under federal, state, or local law. EEO is the Law Poster at http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf JOIN OUR TALENT NETWORK at http://www.jobs.net/jobs/pae/join PAE is a leading provider of enduring support for the essential missions of the U.S. government, its allied partners and international organizations. With over 60 years of experience, PAE supports the execution of complex and critical missions by providing global logistics and stability operations, technical services and national security solutions to customers around the world. PAE has a workforce of approximately 15,000 people in over 60 countries on all seven continents and is headquartered in Arlington, VA. In compliance with the ADA Amendments Act (ADAAA), should you have a disability and would like to request an accommodation in order to apply for a currently open position with PAE, please call Recruiting at (703) 656-6064 or email email@example.com with "Disability Assistance" in the subject line.
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