Adjudicator Job Description Samples

Results for the star of Adjudicator

Claims Adjudicator II - Grade 6 - Temporary

Adjusts and Adjudicates multiple lines of business for first pass in a timely manner to ensure compliance to departmental and regulatory turn-around time and quality standards. Reviews claims and makes payment/adjustment determination to ensure all components, ie., member, provider, authorization, claim and system are valid and correct for accurate processing. Conducts research regarding claim completion and appropriateness; identifies errors and takes necessary actions to resolve claim. Manages work to meet regulatory guidelines. Essential Functions:

  • Reviews claims and makes payment determination with authorization limit to a specific dollar limit (ie. $19,999/claim.).

  • Checks with Lead and Supervisor for any claim exceeding specific dollar threshold (ie. $19,999).

  • Reviews and evaluates claims for proper and correct information including, correct member, provider, authorization, and billing information on which to base payment determination.

  • Refers to eligibility, authorization, benefit, and pricing information to determine appropriate course of action (i.e. claim reject / denial, request for additional information, etc.).

  • Conducts research regarding coordination of benefits issues, fraud and abuse, and third party liability.

  • Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but not limited to CMS, DMHC, DOC, DHS and requirements of accrediting agencies such as NCQA.

  • Prepares material for audits and provides assistance to Lead and Supervisor during audit.

  • Assists with the preparation of materials for audits (including Quality, Compliance, and Regulatory audits) and provides assistance to Lead and Supervisor during audit.

  • Review member/provider claims by checking provider service contracts and other supporting claims documentation in accordance with service agreements.

  • Coordinates payment agreements with providers, working with appropriate MSA and Regional Contracts Department staff.

  • Proactively works to ensure claim review is resolved appropriately. Qualifications: Basic Qualifications: Experience

  • Three (3) years medical claims adjudication experience.

  • Experience in processing multiple types of medical claims and lines of business required (inpatient / outpatient, third party billing, hospital, and professional.) Education

  • High School Diploma or GED required. License, Certification, Registration

  • N/A. Additional Requirements:

  • Knowledge of claim processing regulatory guidelines / mandates, ie HIPAA, Timeliness Standards, Medical Terminology, COB / TPL/ WC insurance guidelines.

  • Knowledge of various payment methodologies&government reimbursement guidelines.

  • Knowledge of claims categorization / codification guidelines (Revenue Codes, Occurrence&Condition codes, CPT/HCPCs codes, ICD9 and ICD10 Diagnosis&Procedure Codes).

  • Must pass basic PC Skills test.

  • Must pass medical terminology test.

  • Related Experience Field: Medical Claims Experience.

  • Working knowledge of CPT, ICD-9, ICD-10, Medical Terminology, COB/TPL/WC. Excellent verbal, written and analytical skills.

  • Demonstrate ability to utilize Medical Terminology and International Classification Diagnosis (ICD-9, ICD 10) coding at a level appropriate to the job.

  • Must be able to work in a Labor Management Partnerships environment. Preferred Qualifications: - Four (4) years medical claims adjudication experience preferred in processing multiple types of medical claims and lines of business (inpatient / outpatient, third party billing, hospital, and professional.

  • Experience with SNF, DME, or Home Care/Hospice Claims processing preferred.

  • Excellent skills in communication preferred.

  • Medical Terminology Certificate preferred. Skills Testing*: PC skills test and Medical Terminology

COMPANYKaiser Permanente

TITLE *Claims Adjudicator II - Grade 6

  • Temporary*

LOCATIONWalnut Creek, CA

REQNUMBER610524 External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.

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Claims Adjudicator

Description: Find what you’re looking for in your career, at PacMed as a Claims Adjudicator (TEMPORARY) in Seattle, WA. This is a Temporary Full Time position in our USFHP department and is eligible for benefits. We are seeking a Claims Adjudicator who will adjudicate claims submitted by outside purchased services for PMC’s enrolled capitated population and communicates those actions. The Adjudicator will adjust complex claims for advanced processing needs, as well as respond to Customer Service Requests and resolve problem claim situations. In this position you will:

  • Adjust claim benefit payments on the GE Centricity computer system; including manual calculations of complex items and manual adjustment to the system as needed to correctly adjudicate claim benefit payment for plan benefits, enrollment contracts, reimbursement schedule, provider contracts, and referral authorization.

  • Adjudicate Universal Billing (UB) and HCFA claims for assigned lines of business (one or two of: Commercial, Medicare, Healthy Options, Basic Health Plan, USFHP) Have experience with areas of specialty claim processing (COB, Adjustments, Point of Service, Home Health and Encounters).

  • Adjudicate claims in accordance with all legislative and regulatory compliance requirements including Medicare Regulations, Medicaid Regulations, Washington State Insurance Code, state legislative mandates, Health Care Financing Administration (HCFA) regulations, Office of the Insurance Commissioner (OIC) requirements, and contractual obligations with other entities (such as Health Plan contractual delegation agreements).

  • Research unclear and unusual claims. Determine the delegation status of claims and prepare claims for submission to appropriate entity.

Qualifications: Required qualifications for this position include: + High School Diploma or equivalent experience in Health Care Business Administration.

  • A minimum of 2 years’ experience in Managed Care operations, including a minimum of one year claims processing experience, in a TPA, MSO, HMO, PHO or large group practice setting.

  • An understanding of financial/administrative/clinical business functions and the interfaces/relationships between applications in healthcare.

  • An understanding of healthcare delivery systems, healthcare insurance, managed care, third party administration, HMOs, preferred provider networks, delegation and risk products.

  • An understanding of provider reimbursement practices including capitation, sub-capitation, case rates, global rates, per diems, percentage discounts, usual and customary fee schedules, RVU and RBRVS-based fee schedules, purchased repriced network, and health plan specific schedules.

  • Experience with information systems supporting the administration of managed care products.

  • Knowledge of CPT, ICD9, HCPCS, RBRVS, ASA, and medical terminology.

  • Typing and 10-key skills (40 wpm and 100 spm) and CRT experience. Preferred qualifications for this position include:

  • Experience with GE Centricity healthcare software application.

  • Experience in CHAMPUS, Medicare and/or Medicaid benefits/programs.

  • An understanding of the principles, theories, and practices of benefit design, plan inclusions and exclusions, healthcare administration rules and regulations, subrogation, third party liability, reinsurance, and coordination of benefits.

Pacific Medical Center

: Pacific Medical Center is an expanding network of outpatient clinics providing primary and specialty care to the greater Seattle area and employing more than 150 providers representing most medical specialties. Pacific Medical Centers is affiliated with Providence Health & Services, which operates 28 exceptional not-for-profit hospitals and more than 350 clinics across the West. With hundreds of physician and advanced practice provider opportunities in virtually all specialties at any given time, Pacific Medical Centers and Providence offer diverse locations, lifestyles and practice models. Find what you are looking for in your next practice opportunity with Pacific Medical Centers! Learn more at . We offer a full comprehensive range of benefits — see our website for details —

Our Mission Our mission is to provide respectful, high-quality, patient-focused healthcare to each person and to the communities we serve.

About Us Quality and respect. These are the words Pacific Medical Centers (PacMed) employees live and work by. PacMed is a private, not-for-profit, primary and integrated multispecialty health care network with 11 outpatient clinics across the Puget Sound region and more than 150 primary and specialty care providers. Affiliated with the Providence Health & Services system, PacMed provides patient-focused health care — and even same-day appointments — to nearly 100,000 patients in King, Snohomish and Pierce counties. We provide immediate access to cutting-edge technology, first-class facilities and board-certified specialists, many of whom have been listed as among “Seattle’s Best Doctors.” Pacific Medical Centers, PacMed, and their Affiliates' (collectively “PacMed”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. PacMed does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Schedule: Full-time



Job Category: Billing / Insurance

Location: Washington-Seattle

Req ID: 166106

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Electronic Claims Adjudicator

Electronic Claims Adjudicator Category: Administrative Support/Clerical Facility:

UCSF Benioff Children's Hospital Oakland, Finance Center Department: CHO Children First Medical Group Schedule: Full Time Shift:

Day Shift Hours: 40 hrs/week Mon-Fri FTE: 1.00000 Job Details: High School/GED 3 to 5 Years of Experience Required Job Summary: Responsible for making sound decisions regarding the review, payment and denial of adjudicated claims.

Must adjudicate accurate claims and meet all quality standards with an error ratio less than 4.5%. Accountable for editing claims received via Electronic Data Interchange (EDI) for adjudication according to department policies and procedures and industry standards. Job Requirements: Education: High school degree/GED, Associate of Arts degree preferred.

Experience: Minimum of three to five years experience of previous medical insurance claims required. Minimum of three to five years experience of eligibility verification and reconciliation required. Knowledge/Skills:

Knowledge of medical care delivery systems benefits and Medi-Cal government sponsored programs. Excellent interpersonal and communication skills. Knowledge of medical community.

Excellent organizational skills with attention to detail. Physical Requirements;Sit: Up to 8 hours/day Stand/Walk: 3-6 hours Bend/Stoop Up to 3 hours Reach:

Up to 3 hours Rep Use of UE/Grasp: Up to 8 Lift/Push/Pull: 15lbs This job requires the ability to hear alarms clients and/or instruction. The ability to see accurately from 20 inches to 20-ft.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function of this position. 3 UCSF Benioff Children's Hospital Oakland is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status. UCSF Benioff Children's Hospital Oakland seeks candidates whose skills, and personal and professional experience, have prepared them to contribute to our commitment to diversity and excellence, and the communities we serve.

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Adjudicator -Full Performance

Supporting the Most Exciting and Meaningful Missions in the World Adjudicator -Full Performance Responsibilities: 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 Qualifications:

  • 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 JOIN OUR TALENT NETWORK at 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 with "Disability Assistance" in the subject line.

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Adjudicator - Ts/Sci Required

Job Description: Adjudicator tasks shall include: 1.

Work on personnel security cases assigned by the Government. Each case will vary in the total tasks, time and effort required to provide the deliverable, which is a written recommendation to grant, suspend, disapprove, or revoke sensitive security accesses; 2. Review and analyze assigned case files to determine if additional security processing needs to be performed in order to render an adjudicative decision.

If additional security processing is necessary, the Contractor shall recommend to the Government as to what additional processing requirements should be conducted; 3. Review the results of all security processing to glean facts and data relevant to the final recommendation; 4. Interview Subjects in person, by telephone, or through written correspondence to elicit clarifying information; 5.

Discuss cases with senior adjudicators, Team Chiefs, Branch management, Adjudications Board members, Polygraph Examiners, Background Investigators, Case Processing Personnel, Managers, and Customers to resolve information discrepancies or gaps; 6. Sufficiently analyze case information in order to show a nexus between the behavior of the case subject and the lCD 704 issues sufficient to support a final recommendation; 7. Provide final written recommendations using Government formats that provide sufficient detail to enable the Government to make informed, independent decisions to grant, disapprove or revoke a Subject's security access; 8.

Maintain security files and ensure that duplicate copies of the SF86, unofficial notes, page flags, and other extraneous materials are purged with approval by USG prior to forwarding files to Branch managers or returning case files to the file room; 9. Deliver oral presentations to Branch and/or Division management, the Adjudications Board, and/or other senior organization officials as required; 10. Administer notifications to customers as approved by the USG, update information in the customer data management system, and perform other follow-up actions resulting from the disposition of cases; 11.

Protect all information and data acquired during the preparation of the analysis from unauthorized release and return all adjudicative notes to the Government; 12. Respond in a timely manner to inquiries from the Government on the status of pending cases or any other information pertaining to adjudicative support tasks under this SOW; 13. Provide a draft adjudicative recommendation to the Government for all cases worked.

The Contractor shall subsequently provide a final recommendation to the Government that incorporates any Government comments provided in response to the draft recommendation that are complete, accurate, and free of spelling and grammatical errors. For each case completed, a written recommendation whether to grant, disapprove or revoke a clearance/approval is required, in accordance with established timelines. 14. Complete cases as identified by the Government. 15.

May be requested to perform 'spot' checks of previously closed adjudicative decisions to ensure they meet Government quality requirements; 16. May also provide Adjudication training and briefings to USG and industry personnel, when approved by the USG. This could include limited TDY travel in CONUS. 17.

Provide a monthly report on the number of cases opened, number of cases closed, number of board cases, number of personal interviews/telephonic interviews and the number of recommendations. Additional duties include: 1. Performs data collection, analysis, interpretation and management duties. 2.

Develops rules and methodologies for data collection and analysis. 3. Ensures the integrity of project data, including data extraction, storage, manipulation, processing and analysis. 4. Consults with the external clients and internal staff to determine data management needs and objectives. 5.

May be responsible for database design, administration, security, and maintenance. 6. Prepares presentations that reflect the results of the data analysis. 7. Provides data-related training to staff. 8.

Coordinates with scientists and other technical experts to design and develop statistical analyses methodologies. 9. Maintains current knowledge of relevant technologies as assigned. 10. Participates in special projects as required.

Education Bachelors Degree in a Computer Science, Statistics or a related technical discipline, or the equivalent combination of education, technical certifications or training, or work experience. Qualifications 2-5 years of related statistics/data analysis experience. Quals include: 1.

Experience performing Background Investigations, Counterintelligence, or Personnel Security for US Government clearances 2. Knowledge of lCD 704 and Executive Order 12968; 3. Knowledge and proficiency in the use of Microsoft Office Suite. 4.

Direct experience as an adjudicator with USG 5. Excellent elicitation skills, both oral and written 6. Exceptional organizational skills As a trusted systems integrator for more than 50 years, General Dynamics Information Technology provides information technology (IT), systems engineering, professional services and simulation and training to customers in the defense, federal civilian government, health, homeland security, intelligence, state and local government and commercial sectors.With approximately 32,000 professionals worldwide, the company delivers IT enterprise solutions, manages large-scale, mission-critical IT programs and provides mission support services.GDIT is an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Protected Veterans/Individuals with Disabilities.

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Automotive Mechanical Warranty Claims Adjudicator

Do YOU have Mechanic, Technician or Service Advisor Experience ?If so, NATIONAL AUTOMOTIVE EXPERTS can help you drive your careeer forward to the next level as a Mechanical Claims Represntaive!

The Company:

NAE is a growing administration company that services and supports the automotive, RV and Power Sports industries. We are dedicated to excellence and committed to innovation and technology. We provide industry leading products, services and support that will assist our clients in exceeding their goals. We are innovative and adaptable to our clients needs.

We provide a culture unlike any other which continuously challenges and rewards employees.

The Position:

As a Mechanical Claims Reprentative, YOU will be responsible for:

  • Retrieving and review maintenance schedules (utilizing Edmunds or manufacturers resources) to fill out maintenance sheet.
  • Requesting any additional information that you may need to make the best possible decision.
  • Ordering inspection if required/discrepancies.
  • Assisting other Claim team members with the claims process.

As a Mechanical Claims Rep, you will answer inbound calls from service repair facilities and customers looking for claim guidance and approval. While on the phone, you will retrieve the customer agreements/contracts via our internal system to confirm coverage and accurately apply the contracts contents. You will actively listen and ask questions to clearly understand the reasoning behind the repair order, verify the cost of labor and parts utilizing the Mitchell and ALLDATA websites and make a determination regarding the claim request. After a determination is made, you will document the details of the calls in our system

Don't miss YOURopportunity to earn a lucrative earning based on the quarterly bonus program!

We are looking for positive, customer-focused individuals who are detail-oriented and have proven problem-solving skills. We take pride in working with a sense of urgency while building relationships that consist of an ethical foundation. We reward team members who work towards providing exceptional service levels via a monthly bonus program.


  • High School Diploma or equivalent.
  • ASE certification (Master-certified eligible) is a plus but not mandatory.
  • Thorough understanding of mechanical automotive repair and documentation procedures.
  • Previous customer service experience; preferably in an auto dealership or over the phone.
  • Ability to accurately and efficiently type notes.
  • Ability to read, understand and apply contact language.
  • Experience using Mitchells, ALLDATA and Edmunds.
  • Excellent written and verbal communication and interpersonal skills


We are located right off I-71 with access to all major highways, including the Ohio Turnpike. Close proximity to shopping and tons of dining options. Just 20 minutes from Downtown Cleveland.

Why should you Apply?

  • We provide a competitive benefit package to our associates which includes affordable healthcare, flexible spending accounts, disability and life insurance, 401(k), 401(k) guaranteed benefit, paid time off, paid holidays, flexibility and more!
  • Excellent Referral Bonus Program- Earn cash by spreading the word about our job opportunities to people to you already know.
  • Attendance Bonus Program- Get paid for coming to work!
  • Beautiful working facilities equipped with multiple breakrooms with flat screen TVs, Wii U system, ping pong table and a popcorn machine!
  • Philanthropy! We provide year-round support to The Cleveland Christian Home.

Interested Candidates can send resumes to (see below)

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L&I Medical Treatment Adjudicator 1

Description Are you searching for an active role in a high performance team? If this is you, the Medical Bill Payment Unit has the spot for you.

In this job, you'll be responsible for timely and accurate bill payments while delivering high quality customer service to external and internal stakeholders. You'll provide consultative services to medical, and other providers, and/or department staff regarding bill payment policies and procedures, laws and administrative rules. As a member of this team, be prepared for a very fast paced environment and we need people who can thrive and effectively multi task in this setting.

There is a 6 month evaluated training period which includes formal training in a classroom setting.

This must be successfully completed prior to being released to work a caseload. The second phase of training includes evaluated caseload management. Some of what you'll do: * Analyze and resolve billing problems according to agency policies, the medical aid rules, maximum fee schedules, Washington Administrative Codes and Revised Codes of Washington.

  • Assist providers of service or injured workers and advise them on how to properly submit bills.

  • Make adjustments to previously adjudicated bills to ensure correct payment levels are made for the type and extent of service.

  • Utilize computer systems and programs specific applications such as ORION, LINIIS, MIPS, MPOS, and Outlook, the Internet.

  • Evaluate and process all incoming and outgoing correspondence associated with billing inquires, take action appropriately and within quality and timely standards. Who should apply? Graduation from high school and 2 years of experience involving work with industrial insurance claims or in processing financial records, such as accounts receivable, payrolls, bill payment, claims adjusting, military medical corpsman, medical social worker or in closely allied field. Additional college or business school education or qualifying experience may be substituted, year for year, for experience or education. Here's what we're looking for: * Clearly communicate with health care providers, attorneys, injured workers and other ancillary providers.

  • Ability to access and move between multiple computer programs, such as databases, word processing programs, Outlook and the internet.

  • Provide customer service by listening attentively, identifying issues, and exercising knowledge of laws and regulations to assist others.

  • Make good decisions by prioritizing and performing multiple tasks simultaneously, handle interruptions appropriately, and return to the incomplete tasks.

  • Able to write effectively in accordance with generally accepted business standards.

  • Professionals who can maintain proficiency and accuracy while responding to frequent interruptions.

  • The ability to work in collaboration within designated work group as well as with other teams/other areas of the agency is strongly desired.

Note: In addition to your application, the process requires that you include a cover letter/letter of interest clearly addressing the above section of job announcement titled: "Who should apply" and "What we are looking for". Please attach while in the on-line application process.

Supplemental Information This job announcement may be used to fill multiple vacancies. Application review starts immediately and the hiring authority reserves the right to offer the job at any time. It's to your advantage to apply quickly.

Employees driving on state business must have a valid driver's license. Employees driving a privately owned vehicle on state business must have liability insurance on the privately owned vehicle. Prior to any new hire into L&I;, a background check, including criminal record history, will be conducted. Information from the background check will not necessarily preclude employment but will be considered in determining the applicant's suitability and competence to perform in the position. To apply, follow the "Apply" link above

Jobs advertised as Open Continuous will be closed without notice. Apply quickly! We're looking for evidence that you have what we're looking for.

Your application materials will be used for deciding who'll be selected for interview. For more information about the Department of Labor & Industries visit: OR Contact us at: L&I; strives to attract and retain a high-performing and diverse workforce in which our differences are respected and valued to better meet the needs of the diverse customers we serve.

L&I; fosters an inclusive environment that promotes safety, collaboration, flexibility and fairness so that all employees can participate and contribute to their full potential. This position is represented by the Washington Federation of State Employees (WFSE). That means that, as a condition of employment, no later than the 30th day following the beginning of your employment, you must pay the

WFSEeither membership dues, a representation fee or, for bona fide religious non-associators an amount equal to dues to be used in a program within the union in harmony with the employee's conscience.

Persons with a disability, who need assistance in the application process, or those needing this announcement in an alternative format, may call (360) 902-5700. Applicants that are deaf or hard of hearing may call through the Washington Relay Service at 7-1-1.The State of Washington is an Equal Opportunity Employer

If you have specific questions regarding this position, please contact Trish Lamb at 360.902.5709 or email Please do not contact to inquire about the status of your application.Salary: $2,848.00 - $3,700.00 Monthly Location: Thurston County – Tumwater, WA Job Type: Full Time - Permanent Department: Dept. of Labor & Industries Job Number: 2017-08299 Closing: 9/24/2017 11:59 PM Pacific Agency: State of Washington Address: View Job Posting for Agency Information View Job Posting for Location, Washington, 98504. Phone: View Posting for Agency Contact Website:

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Adjudicator II, Claims

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

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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

Minimum Qualifications: + 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 Responsibilities: + 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.This position is contingent upon contract award and government funding

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

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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 claim data, determine eligibility status, and review & adjudicate claims within established timeframes. Will effectively utilize the RIMS/Javelina claim processing system and the IMAX document retrieval system in order to perform the day to day job functions of processing claims.

  • Screen claims for completeness of necessary information.

  • Verify participant/dependent eligibility.

  • Interpret the plan 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 the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered.

  • Determine the need for additional information or documentation from participants, employers, providers and other insurance carriers.

  • 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.

  • Handle assigned claims on a first-in, first-out basis, regardless of complexity/difficulty.

  • Process claim adjustments.

  • Address and resolve Customer Service Inquiries on a timely basis.

  • Performs other duties as assigned within the scope of responsibilities and requirements of the job.

  • High School Diploma / GED + College coursework in area of medical terminology, ICD9 and CPT codes is a plus + Technical training in the area of medical terminology, ICD9 and CPT codes is a plus

  • Minimum of 2 years experience in a group medical claim adjudication environment is desirable + Knowledge of the RIMS computer system is helpful + Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits; and experience with eligibility verification, medical coding, coordination of benefits and subrogation

  • Minimum level computer skills in a Microsoft Office environment: Beginner-Intermediate + Bi- or Multi- lingual skills (written and verbal): A Plus + Effective communication skills, both orally and in writing is required Ability to:

  • Maintain established production levels and excellent quality + Work effectively as a team member within a team-oriented structure is also an important requirement of the position

  • Keyboard 50 wpm + Manage competing deadlines and multiple projects in a fast-paced environment + Perform the essential functions of this job with or without reasonable accommodation ID: 2017-1379 Organization: UNITE HERE HEALTH External Company URL:

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