Independent Health is a Western New York health insurance organization and one of the region’s earliest Health Maintenance Organizations (HMOs). It provides coverage and related services to approximately 355,000 people through more than 100 plans, products, and services. Its work includes commercial health insurance, pharmacy benefits, Medicare Advantage, and self-funded health plans. The company describes its culture as focused on helping members and employees bring out their best.
Claims Adjudicator - Hybrid, Independent Health
Process and review medical and dental claims for Independent Health in a hybrid role. Investigate payment issues, apply benefit and coding rules, and answer client, member, and provider questions.
Description
- Evaluate and adjust medical and dental claims using established criteria and applicable client summary plan descriptions
- Assist Customer Service Representatives by addressing client, member, and provider questions about claim status, benefit structures, and payments
- Process facility, professional, member-submitted, pharmacy, and dental claim edits for both in-network and out-of-network benefits
- Examine vouchers and payment explanations to investigate and correct claims issues
- Achieve department standards for productivity, accuracy, policy knowledge, procedure knowledge, and timeliness
- Investigate policy, payment, and coding discrepancies
- Keep contract, summary plan description, and benefit knowledge current
- Meet department deadlines and turnaround requirements while following state and federal regulations
- Apply critical thinking when processing claims
- Use relevant systems and applications to find claim-specific details
- Find, interpret, and apply appropriate resources to individual claim situations
- Recognize and communicate opportunities to improve processes
- Organize and manage the claim-processing workload effectively
- Work with other Independent Health departments to resolve payment problems
Requirements
- A high school diploma is required
- A medical office assistant certificate or college degree is preferred
- At least six months of medical claims processing, medical billing, or customer service experience is required, preferably in healthcare or social services; comparable experience combinations may be considered
- Understanding of medical billing procedures
- Knowledge of CPT and ICD-9 coding
- Knowledge of medical terminology
- Proficiency in data entry and Microsoft Office applications
- Strong organization skills with careful attention to detail and follow-through
- Effective written, verbal, and interpersonal communication skills
- Ability to communicate effectively with internal and external customers
- Ability to work collaboratively with others
- Willingness to work additional hours when needed
- Ability to demonstrate Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust
- Ability to work onsite at the Williamsville location as required by the hybrid arrangement
- Immigration or work visa sponsorship is not available
Benefits
- Access to a first-class perks and benefits package
- A workplace culture centered on growth, innovation, and collaboration
- Eligibility for scorecard incentives
- A comprehensive benefits package
- Generous paid time off
- Professional development and career advancement opportunities