Certified Claims Processor I

Essential Duties: Processes professional claims across multiple lines of business by reviewing claim and line-level details to ensure accurate adjudication in accordance with established policies and procedures. Interprets and applies coding guidelines (CPT, HCPCS, ICD-10), benefit plans, and contract language to determine appropriate claim outcomes, including pricing, payment, and denial decisions. Reviews and resolves claim edits, denials, adjustments, and reprocessing requests by analyzing claim and line-level data, including potential coding discrepancies, system configuration issues, or policy misalignment. Applies benefit plans, reimbursement methodologies, and regulatory requirements to ensure accurate outcomes. Evaluates pending claims to identify root causes of processing issues, including eligibility discrepancies, authorization requirements, or billing errors, and determines appropriate corrective actions. Coordinates benefits by reviewing member eligibility, other insurance information, and payer responsibility to ensure accurate application of coordination of benefits (COB) rules. Reviews provider disputes, reconsiderations, and appeals by analyzing original claim processing, supporting documentation, and applicable policies to determine if reprocessing or adjustment is warranted. Applies knowledge of reimbursement methodologies, fee schedules, and pricing logic to ensure claims are paid in accordance with contract terms and regulatory guidelines. Identifies trends or recurring issues in claim processing, including system errors, configuration gaps, or provider billing patterns, and escalates findings to leadership as appropriate. Communicate effectively with internal teams and providers to clarify claim details, explain adjudication outcomes, and resolve processing issues in a professional and timely manner. Maintains compliance with HIPAA and protects PHI by ensuring all claim handling, communication, and documentation meet confidentiality and security standards. Adheres to claim routing, inventory control procedures, and workflow processes to ensure timely and accurate claim processing within established turnaround times. Participates in ongoing training and continuing education to maintain coding certification and stay current with changes to coding guidelines, reimbursement methodologies, and regulatory requirements. Maintains punctual, regular, and predictable attendance while meeting established productivity and quality benchmarks. Respectfully takes direction from Department leadership. Performs other duties as assigned.

Qualifications: Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education: Associate's degree (AA) from a two-year college or technical school in equivalent combination of education and experience is required.

Interpersonal Skills: Demonstrate accountability, inspiring trust and confidence from others. Work with high initiative, energy and effectiveness in a fast-past environment. Collaborate within a multidisciplinary, diverse team to provide professional service. Interact positively with customers to satisfy needs and resolve problems in a pleasant and professional manner. Prioritize and organize work according to competing timelines. Allocate your time so that you can complete tasks within established deadlines. Adapt to change, learn quickly, and work with ambiguity. Maintain an attentive and empathetic demeanor. Maintain a high degree of professionalism and confidentiality. Take initiative and apply sound judgment in completing tasks and responsibilities.

Language Skills: Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization. Mathematical SkillsAbility to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs. Computer SkillsHas advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data.

Reasoning Ability: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to work with problems involving a few concrete variables in standardized situations.

Physical Demands & Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties. The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate. The employee must be able to work onsite, as needed. The employee may be able to work from a home office occasionally.