Job Description
Job Summary:
The Claims Adjudicator III is responsible for processing a wide variety of claims within department standards and act as a technical resource to all Claims team associates.
Essential Functions:
Process a wide variety of claims (at all pend levels) within department standards
Research and resolve claims with "error messages" by researching and correcting codes, units, etc.
Constructively interact with other departments such as Enrollment, Medical Management, Provider Operations, and Configuration to facilitate claim processing
Recognize claims for possible fraud, waste, or abuse
Process exception claims within timely filing limits
Act as a technical resource to all Claims team associates by reviewing claims, training, providing job shadowing and answering questions
Identify potential process improvements and participate and/or facilitate related initiatives
Professionally and competently serve as Subject Matter Expert on claims processing both internally within Claims Department and other CareSource departments and externally as needed (regulators, auditors, etc.)
Perform any other job duties as requested
Education and Experience:
High School Diploma or equivalent required
Post-secondary academic coursework, degree, or certification in Healthcare related field is preferred
Minimum of three (3) years of health insurance claim adjudication experience is required
Medicaid managed care claim adjudication experience is preferred
One (1) year recent CareSource Claim Adjudication experience is preferred
Competencies, Knowledge and Skills:
Intermediate computer skills such as Excel, Word and Outlook
Medical terminology; CPT-4 and ICD-10 coding knowledge required
Written and oral communication skills
Ability to work independently and in a team environment
Attention to detail
Ability to remain focused in a production environment
Proven knowledge of multiple products and reimbursement methodologies
Knowledge of Medicaid
Critical Listening and Thinking Skills
Training/teaching skills
Time management skills
Customer service oriented
Decision making/problem solving
Leadership skills
Licensure and Certification:
None
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Flexibility to meet training schedules within standard scheduled hours
Some weekends may be required based on business needs
Compensation Range:
$40,400.00 - $64,700.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type:
Hourly
Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
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CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law.
