Claims Adjustor

This is a fully remote position, open to applicants in United States.

📋 Description

• Reviewing and adjudicating claims within designated work queues according to Centivo’s established Policies and Procedures and the terms outlined in the Summary Plan Documents (SPD’s) for Centivo’s clients.

• Thoroughly examining all system-generated edits applied to claims in the Claims Adjustor’s designated queues before releasing claims to ensure that benefits are aligned with the client’s SPD and that client funds are managed correctly.

• If the Claims Adjustor identifies a potential issue or inconsistency in the interpretation of a Plan regarding how benefits are applied by the system, promptly escalate the claim to the Plan Build/System Configuration Team for resolution.

• When the Claims Adjustor cannot resolve an edit due to provider selection, pricing, or customary discrepancies, immediately refer the claim to the Provider Maintenance and/or Pricing teams for resolution.

• In instances where the Claims Adjustor cannot resolve an edit based on the information included or attached to a claim, appropriately deny the claim for additional information and generate correspondence to the participant or provider clearly outlining data requirements. Upon receiving the requested data, reopen the denied claim and re-adjudicate based on the new information.

• Maintain the required daily, weekly, and monthly production levels as documented in the Claims Department Policies and Procedures.

• Engage in departmental quality improvement initiatives and propose process enhancements that will boost efficiency; challenge any process or policy that adds unnecessary steps or workload for the Claims Adjustor and recommend alternative solutions.

• Process claims in accordance with established policies and procedures, contacting providers as necessary, and completing tasks with moderate supervision. Responsible for achieving the production and quality targets set by department leadership.

• Additional responsibilities may include assisting and mentoring less experienced team members, participating in various initiatives or projects within the Claims Delivery Team, documenting processes, performing advanced tasks, supporting high-dollar reviews, and managing overpayments/refunds.

⛳️ Requirements

• Previous experience with a highly automated and integrated claims processing system.

• Experience with HealthRules Payer is preferred.

• Knowledgeable in healthcare claims, medical coding, and the rules applicable to Benefit Plans.

• Strong critical thinking abilities and a willingness to make independent decisions with minimal supervision.

• Excellent verbal and written communication skills.

• Demonstrated ability to thrive in a fast-paced environment while managing multiple issues under the pressure of production schedules and deadlines.

• Proven capability to work independently for the majority of the day.

• Proficient in Microsoft Office applications and other web-based software applications.

• Ability to learn new proprietary computer systems.

• High School diploma or GED is required.

🏝️ Benefits

• Opportunities for Equity.

• Bonus offerings available.