Lead Claims Processor

Job ID: J123407
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 23, 2018

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Description

JOB SUMMARY

This job serves as the unit subject matter expert with a primary focus of coaching and addressing questions for the unit staff members.  Researches and/or resolves the most complex issues that are unable to be handled through normal process documentation.

ESSENTIAL RESPONSIBILITIES

  • Maintain and increase internal company relationships by interacting with staff regarding claims issues.
  • Frequently contact customers or other involved parties to update information to claim files.
  • Utilize an in depth understanding of billing and follow up regulations for electronic claims editing and submission.
  • Demonstrate success working in a team environment while independently completing assignments consisting of numerous steps that vary in nature and sequence.
  • Resolve and adjust claims, selecting from alternative methods deemed not solvable by adapting and interpreting policies and processes.
  • May train lesser skilled employees on detection methods regarding waste, fraud, or abuse in claims processing.
  • Assist supervision with establishing or revising published metrics.
  • Other duties as assigned or requested.

EDUCATION

Minimum

  • High School Diploma/GED

Preferred

  • None

EXPERIENCE

Minimum

  • 3 - 5 years of related, progressive experience in claims processing

Preferred

  • Advanced training or certifications in claims processing from community college or private educational institutions

LICENSES AND CERTIFICATIONS

Minimum

  • None

Preferred

  • None

SKILLS

  • Knowledge and skills to create and distribute weekly and monthly reports, including exception reporting
  • Ability to review claims and answer questions from processors on re-evaluation requests, closed claims, and resolution codes
  • Ability to assist supervision in a variety of administrative matters regarding trending metrics related to claims processing quality, efficiency, and effectiveness
  • Ability to assist supervision to resolve issues or problems that arise with current computer databases
  • During claims investigations, ability to interact successfully with other company departments outside of immediate supervision
  • For claims needing adjusting, ability to track such claims with a clear and concise explanation

TRAVEL REQUIREMENT:
None

LANGUAGE REQUIREMENT (other than English)?  

None

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.

Position Type:

Office-Based

Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches/Trains others regularly

Frequently

Travels regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (Sales employees)

Does Not Apply

Physical Work Site Required

No

Lifting: up to 10 pounds

Rarely

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

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 (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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