Claims Processor

Buffalo (hybrid remote) Cintivo. Claims Processor. $18 - $20/hour. We exist for workers and their employers - who are the backbone of our economy. That is where Centivo comes in - our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Centivo is looking for Claims Processors to join our team As a Claims Processors you will manage and processes healthcare claims for our self-funded employer groups. Health care providers treat patients, then file medical claims to receive payment from the patient's Benefit Plan. Claim Processors review and assess the claims, adjudicating payment to the provider on behalf of the Plan if a claim is covered by the patient's Benefit Plan. Claims Processors are responsible for working closely with the Claims Supervisor, Account Managers, System Configuration and Quality Assurance Team in ensuring that claims received by Centivo are adjudicated in a timely manner and accurately. Claims Team roles are based on skill level and increased responsibilities. What you'll do: Adjudicating claims in assigned work queues based on Centivo's written Policies and Procedures and the terms of the Summary Plan Documents (SPD's) for Centivo's clients. Diligently reviewing all system-generated edits which have been applied to claims in the Claims Processor's assigned queues prior to releasing the claims to ensure benefits are being applied per the client's SPD and client funds are being appropriately managed. When the Claims Processor believes there may be an issue or inconsistency in the interpretation of a Plan as the system is applying benefits, immediately route the claim to the Plan Build/System Configuration Team for resolution. When the Claims Processor is unable to resolve an edit based on the provider selection, the pricing and/or usual and customary discrepancies, immediately route the claim to the Provider Maintenance and/or Pricing teams for resolution. When the Claims Processor is unable to resolve an edit based on the information included with or attached to a claim, appropriately deny the claim for additional information, and generate correspondence to the participant or provider concisely explaining data needs. When such additional data is received, reopen the denied claim, and re-adjudicate based on the information. Maintain daily, weekly, and monthly required production levels documented in Claims Department Policies and Procedures. Participation in Departmental quality improvement efforts and bring forward process improvement suggestions that will improve efficiencies; question a process or policy that creates additional steps or work on the Claims Processor and suggest an alternative solution. Processes claims in accordance with established policies and procedures, contacting providers as needed, completing tasks under moderate supervision. Responsible for meeting the production and quality goals determined by the department leadership. You should have: Prior experience with a highly automated and integrated claims processing system. Knowledge about healthcare claims, medical coding, and rules applicable to Benefit Plans. Critical thinking skills and willingness to make independent decisions with little supervision. High School diploma or GED required Excellent oral and written communication skills. Proven ability to work in a fast-paced environment managing multiple issues with pressure of production schedules and deadlines. Proven ability to work independently for majority of day. Proficiency in Microsoft Office applications and other web-based software applications. Ability to learn new proprietary computer systems. These are not required, but would be nice to have: Associate or bachelor's degree Follow link to apply through company website:

Created: 2024-11-02