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

📋 Description

• Evaluate healthcare claims in accordance with specific employer and payer policies and procedures.

• Analyze claims processing data to ensure compliance with CMS and billing standards.

• Assess medical claim attachments and documentation to verify medical necessity and benefit eligibility.

• Examine claim and line-item adjustments to ascertain proper payment amounts.

• Redirect claims to specialized internal and external resources as necessary.

• Communicate with various departments to facilitate claims processing.

• Achieve performance metrics outlined in scorecards while meeting production and quality benchmarks.

• Investigate complex claims for accuracy, completeness, benefits, eligibility, Coordination of Benefits (COB) requirements, and provider status.

• Utilize multiple systems and interfaces to gather and document claim information.

• Address claim disputes, including urgent requests from internal departments.

• Identify potential issues related to claim systems or provider contract configurations and relay them for resolution.

• Offer insights on quality trends and opportunities for process enhancements.

• Collaborate with colleagues and business partners to meet productivity and accuracy goals.

• Engage in special projects as assigned.

• Mentor less experienced associates to enhance team and departmental knowledge and performance.

• Execute additional responsibilities as designated by Claims Leadership.

⛳️ Requirements

• High School diploma.

• Experience as a Claims Examiner I or relevant background in healthcare.

• Strong verbal and written communication abilities.

• Proficiency in MS Office applications.

• Collaborative team player.

• Ability to work independently with minimal supervision.

• Innovative thinker with effective problem-solving skills in healthcare claim adjudication.

• Strong work ethic with the capability to manage multiple tasks as needed.

• Applicants for this remote position must reside in the state of Nebraska or the local Omaha metro area.

🏝️ Benefits

• Comprehensive Total Rewards package.

• Equal Opportunity / Affirmative Action Employer.

• Support for disability accommodations.