Position Description: The position processes claim adjustments within established timeframes. Process adjustments in the FACETS system utilizing established policies and procedures to review and correct error and warning messages. Utilize various tools within the FACETS system and other CBC systems to research claims to ensure proper adjudication. Partner with other CBC departments and CBC vendor partners as needed to complete claim adjudication. Communicate with providers as needed to obtain information needed to process. Must perform all duties in compliance with HIPAA regulations. Responsibilities and Qualifications:
Essential Duties & Responsibilities:
Adjudicate claim adjustments in FACETS by researching and resolving error and warning messages within established timeframes. 55%
Utilize various tools within the FACETS system and other CBC systems to research claims to ensure proper adjudication 5%
Partner with other CBC departments and CBC vendor partners as needed to complete claim adjudication. 10%
Review and take necessary action as needed in response to inquiries from internal business partners, through Facets inquiries, e-mail, and imaged paper correspondence. 15%
Perform outreach (both verbal and written) to providers as needed to obtain additional information to process adjustments. 10%
All other duties and assignments as directed. 5%
Qualifications:
- Must possess a strong attention to detail and an interest in preventing errors
- Demonstrate critical thinking, problem solving, and decision making abilities
- Demonstrate ability to be independent, self-sufficient, dependable and professional
- Demonstrate intrinsic initiative and time management skills
- Must possess a strong commitment to teamwork and an ability to foster an inclusive culture of diversity by working well and collaborating with others as needed
- Ability to thrive in a dynamic working environment, multi-task, and adapt quickly
- Ability to accept feedback, learn, and adapt from guidance to be successful
- Ability to mentor peer group in best practice standards as well as positively spread continuous changes to processes and the responsive health care environment
- Must demonstrate effective verbal and written communication
- Ability to adapt to constant changing priorities and keeping daily responsibilities on task
- Ability to manage workload and ensure all tasks are completed within established timeframes
- Must be willing and able to work possible mandatory overtime as needed based on business needs
- Foster an inclusive culture of diversity, working well with others
- Must be able to meet quality, productivity, and behavior expectations
Knowledge, Skills, and/or Abilities:
- Knowledge and familiarity with claims processing, FACETS, Work Desk, and HIPAA policies and regulations preferred
- Familiarity with Provider and Subscriber billing documents and applicable billing terminology preferred
- Ability to operate a personal computer (PC) and other office equipment (e.g., copy machine, fax machine, printer, calculator, and etc.) as well as possess excellent keyboarding skills
- Demonstrated competency in the use of computer applications, databases, and end user computing tools and programs, including proficiency in various software like Microsoft Windows, Email, Internet browsers, Instant Messenger, and Office (Word, Excel, etc.)
- Must possess basic reading and arithmetic skills (reading and math comprehension)
- Must possess above average verbal and written communication skills
Experience:
- FACETS claims Coding
- Facets claims processing
- FACETS adjustments
Education, Certification, and Licenses:
- Must have a high school diploma or GED.
Work Environment:
- Operations center environment
- Qualified candidate must be able to work a set shift schedule M-F during normal business hours. Weekend overtime hours may be required at times based on business needs.
- Full-time candidates may be eligible to work at home pending corporate and department eligibility criteria, review, and approval of a work at home request
Travel Requirements:
- Amount: 5% of the time
- Some travel may be required for training sessions and/or between buildings
- If working from home, Claims Examiners are required to be readily available to travel to the appropriate work site locations as needed per business needs and in compliance with the corporate travel and work-at-home polices
Physical Demands:
- While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see
- The employee must be able to work over 40 hours per week
- The employee must occasionally lift and/or move up to 5 pounds
Key Interfaces:
- Workflow
- Microsoft Office (Outlook, Word, Excel )
- Availity
