ClaimsProcessor

## **Company :** Highmark Inc. ## **Job Description :** **JOB SUMMARY** This job is responsible for screening, reviewing, evaluating online entry, correcting errors and/or performing quality control review and final adjudication of paper/electronic claims. Determines whether to return, deny or pay claims following organizational policies and procedures. Reviews processed claims and inquiries to determine corrective action including adjusting claims as necessary and takes the corrective action steps using enrollment, benefit and historical claim processing information; may coordinate benefits and interact with customers. Responsible for the timely and accurate completion of claims adjustments which could be a result of internal/external audits, member/provider phone calls, other insurance information received, appeals, and system changes, etc.; provides technical assistance in researching and resolving inquiries. **ESSENTIAL RESPONSIBILITIES** * Receives and processes claims to include entering/verifying claims data; determines if claim information is complete and correct. * Resolves claim edits, reviews history records and determines benefit eligibility for service. Reviews payment levels to arrive at final payment determination. * Elevates issues to next level of supervision as appropriate and ensures a professional line of communication is maintained with internal and external customers. * Meets all production and quality standards, ensuring timeliness and accuracy of all work given by support staff/management. Maintains accurate records, including timekeeping records and attends all required training classes. * ​Other duties as assigned or requested. **EDUCATION** **Required** * High School Diploma/GED **Substitutions** * None **Preferred** * None **EXPERIENCE** **Required** * 1 year of related experience **Preferred** * 1 year of claims processing experience * Inquiry resolution system, OCWA, Oscar, Outlook experience ​ **LICENSES or CERTIFICATIONS** **Required*