Claims Processor

Job ID: J122839
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 10, 2018




This section contains a synopsis of the main purpose(s) or functions(s) of the job, indicating what is done.This information will be used to develop the position posting.

Screens, reviews, evaluate online entry, error correction and / or quality control review and final adjudication of paper/electronic claims.  Determines whether to return, deny or pay claims following organizational policies and procedures.  May include initial entry claims or claims which have suspended.  Translate foreign language claims into English using software and code appropriately.  Convert foreign currency to US dollar and code charges appropriately.  Reviews processed claims and inquiries to determine corrective action which can include adjusting claims. Takes the corrective action steps using enrollment, benefit and historical claim processing information. 


This section lists the major duties and responsibilities of the position.This is not an exhaustive list of all job duties/functions/attributes.Depending on Role, essential responsibilities may also include oversight and management of people and functions described below.

1.Determine if claim information is complete and correct.  Enter/verify claims data. 

2.Resolve claim edits, review history records and determine benefit eligibility for service.  Review payment levels to arrive at final payment determination.

3.Meets all production and quality standards.  Attends all required training classes.

4.Elevates issues to next level of supervision, as appropriate.

5.Maintains accurate records, including timekeeping records.

6.Other duties as assigned or requested.


Education, Experience, Licenses/Certifications


Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job.


High School Diploma/GED required for all levels

Typing speed of at least 60 words per minute

Knowledge, Skills and Abilities  (This section describes additional preferred characteristics)

Ability to take direction and to navigate through multiple systems simultaneously.

Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

Ability to use mathematics to adjudicate claims.

Ability to solve problems within pre-defined methods and guidelines.

Knowledge of operating systems specific to claim processing.

IV. SCOPE OF RESPONSIBILITY  (People Management Responsibility)

Does this role supervise/manage other employees?          No  ×          Yes  □

If yes, indicate the number of direct reports:


The physical environment in which the work is performed is described here.  Adverse environmental conditions such as noise, heat, and fumes are detailed along with the frequency of exposure.  Most positions will indicate that work is performed under normal office conditions.  This section should be updated to indicate differences from normal office conditions.

Is Travel Required?

No   ×

Yes   □

Work Environment

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This job requires the ability to work independently and as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (
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