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Sr Claims Examiner Job in Grove City, Ohio US

Sr Claims Examiner


Posted: 10/22/2021 - Expires: 1/20/2022

Job ID: 233204898


Job Description

As a Sr. Claims Examiner/Auditor at UST HealthProof, this is your opportunity to

*  Be responsible for attending and completing the training scheduled by the client and


*  Be responsible for processing assigned claims based on client-specified guidelines or as

  directed by the team lead

*  Be responsible for meeting complex claims productivity targets of claims per hour or day as

  set by the team lead

*  Mentor junior members of the team

*  Collaborate with other team members on special projects as assigned by the team leads,

  including process documentation, training, quality audit, assist with surge activity for the

  client (s), or any other project as determined by the team lead

*  Develop Knowledge of physician practice and hospital coding, billing and medical

  terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorization and other

  terms, terminology, and concepts of healthcare

*  Develop some level of communication with client Claims managers to address issues,

  concerns and take preventive measures to avoid service quality issues

*  Be responsible for your attendance, time off and reporting shift timings, etc. with the prime

  objective of meeting and exceeding customer deliverables

*  Participate in meetings and project activities outside of the primary location at locations

  determined by the UST management team and team lead

*  Take on health plan administration projects assigned by the team lead from time to time -

  these projects may include provider data, authorization, enrolment, or other health plan

  admin operations.

*  Performs production audits, SLAs audits focused audits and supports customer external audit activity.

Role Proficiency

Job Description

*  High School degree required with one year of relevant professional healthcare claims

  operations for an insurance company or healthcare payor.

*  Willingness to learn new skills and succeed in a new career

*  Excellent verbal and written communication skills.

*  Proficiency with MS Office applications, especially Word and Excel.

*  Team collaborator

*  The ability to adapt quickly to a fast-paced environment, self-starter, and quick learner

*  Excellent written and oral communication skills

*  Be responsible for processing assigned claims based on client-specified guidelines or as

  directed by the team lead

Role Proficiency:

A Voice Associate Able to independently take customer support calls effectively and efficiently ;follow the SOPs to complete the process and endeavour to resolve the issue handle some escalated issues or escalate to a more knowledgeable person to resolve in alignment with SLAs and assists Lead I - BPM.rnA Data Associate should independently be able to effectively and efficiently process the transactions assigned in timely manner clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained in alignment with SLAs and assists Lead I - BPM.


Measures of Outcomes:
   100% Adherence to quality standards
  Adherence to turnaround time for response and resolution
  Completion of all mandatory training requirements
  100% adherence to process and standards
  100% adherence to SLAs where applicable
  Number of issues fixed/tasks completed
  Number of non-compliance issues with respect to SOP
  Zero/No Client Escalations
  Number of high-quality RCA and QA output
  Daily/weekly performance reporting
Mentors A1 and A2 resources on the processes

Outputs Expected:

Processing Data:
 Processing transactions assigned as per SOPs

Handling calls Voice:
 Handle customer support calls resolve issues and complete after-call work

 Take calls (voice) or process complex transactions (data)

Issue Resolution:
 Address any problems with the supervisor/QA to ensure maximum productivity and efficiency.
Identifies analyses and solves the incidents/transactions.

 Proficient in the process assisting other team members who are new to the process as well to ensure quick readiness of the team.
Take steps to improve performance based on coaching.
Production readiness of new joiners within agreed timeline by providing guidance Actively participate in the team's or organization wide initiatives
Able to handle and manage higher complexity tasks.

 Be aware of any clients process or product updates and ensure 100% compliance towards the same.
Adhere to release management process.
Thorough understanding of organization and customer defined process. Consult with mentor when in doubt.
Adherence to defined processes.
Adhere to organization' s policies and business conduct.

 Create reports on specific SLAs/performance measures/KPIs

Stakeholder Management:
 Guide the team in preparing status updates and keep management updated about the status.

Training :
 Attends one on one need-based domain/project/technical trainings as needed.
On time completion of all mandatory training requirements of organization and customer.
Provide on floor training and one to one mentorship for new joiners.

 Escalate problems to appropriate individuals/support team based on established guidelines and procedures.

 Monitor progress of requests for support and ensures users and other interested parties are kept informed.

Manage knowledge:
 Consume project related documents share point libraries and client universities

 Mentor and provide guidance to peers and junior associates.
Assist new team members in understanding the customer environment.

 Status update to the respective stakeholders and within the team

 Collaborate with different towers of delivery for quick resolution (within SLA); document learning's for self-reference.
Collaborate with other team members for timely resolution of errors.

Skill Examples:
   Customer Focus: Focus on providing a prompt and efficient service to customers goes out of the way to ensure that individual customer needs are met.
  Attention to detail to ensure SOPs are followed and mistakes are not knowingly made
  Team Work: Respect others and work well within the team.
  Communication: Speak clearly and write in a clear and concise manner. Uses appropriate style and language for communication (Data)
  Communication: Speaks in an accent neutral manner or with the accent required for the process with good vocabulary and grammar skills. Writes clearly (Voice)
  Typing Speed with 15WPM and 80% accuracy
  Analytical approach: Makes systematic judgments based on information and relevant assumptions.
  Ability to follow SOP documents and escalate the alerts within the defined SLA Willingness and ability to learn new skills domain knowledge etc.
  Make rule based and discretionary decisions.
  Process Trainer/Sr. QA/Domain Expert/MIS Analyst
  Frontline resource - Voice/Backoffice Quality Auditors SME Domain Experts

Knowledge Examples:

Additional Comments:

UST Global celebrates diversity and inclusion. We are an Equal Employment Opportunity employer. We welcome candidates to apply for employment from diverse backgrounds and believe your unique perspective adds to the richness of our company culture. We do not discriminate based upon race, religion, color, national origin, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

Job Summary

Employment Type:
Full Time Employee
Job type:
Federal Contractor
Skill Based Partner:
Education Level:
High school graduate
Work Days:
Mon, Tue, Wed, Thu, Fri
Job Reference Code
Licenses / Certifications:
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