Claims Processor II

Claims Processing Team Member

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

The successful candidate will work as a member of the Claims Processing team, ensuring accurate and timely processing of Physician, Facility, Dental, and Vision claims for multiple plan designs, including traditional PPO plans, Reference Based Pricing (RBP) plans, and Minimal Essential Coverage (MEC) plans. Interprets schedules of benefits and plan documents to apply accurate benefits to claims according to the plan design. Applies internal policy and procedures for claims adjudication, identifies and resolves claim processing errors, adjusts previously processed claims, and logs refunds for claim overpayments. Performs data entry of CMS 1500, UB 04, and dental claims, research claim issues, and assists in audit projects. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge / experience to perform job functions, with supervision ranging from close to minimal oversight based on demonstrated skill and performance levels.

Essential duties and responsibilities include the following. Other duties may be assigned.

• Accurate and timely processing of Physician, Facility, Dental and Vision claims for multiple plan designs, including traditional PPO plans, Reference Based Pricing (RBP) plans and Minimal Essential Coverage (MEC) plans.
• Adhere to Corporate and Departmental standards including production and quality goals.
• Interpret schedule of benefits and plan documents to apply accurate benefits to claims according to the plan design.
• Identify potential system or plan design issues that would impact the correct adjudication of a claim.
• Effectively communicate with the Management team on claim processing questions and issues.
• Interpretation and application of internal policy and procedures for claims adjudication.
• Identify and resolve the root cause of a claim processing and / or data entry error.
• Adjust previously processed claims.
• Identify claim over payments and log refunds.
• Data entry of CMS 1500, UB 04, and dental claims.
• Research complex claim issues.
• Assist in audit projects

No supervisory responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills. One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and / or Experience

GED / HS Diploma and 1+ year experience or equivalent combination of education and experience

Computer Skills

Intermediate knowledge of MS Office / Word, Excel, PowerPoint and Outlook. Experience with Windows based database programs is preferred. Strong aptitude for new programs.

Other Skills and Abilities

Reasoning Ability

Mathematical Skills

Language Skills

Competencies To perform the job successfully, an individual should demonstrate the following competencies :

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.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and / or move up to 25 pounds.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples : business office with computers and printers, light traffic).

This position must work on-site at the Honolulu, Hawaii location for purposes of providing adequate support to internal clients; being available for face-to-face interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as for facilitation of quick and effective decisions through collaboration with stakeholders. Remote work is not an option for these purposes.

This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order to get the job done. Therefore, one must have the ability to work nights, weekends or on holidays as required. This may be changed at any time to meet the needs of the business. The typical working hours for this position are Monday through Friday from 8 : 00am to 5 : 00pm.

This position requires no travel however attendance may be required at various local conferences and meetings.

The Perks :

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male / Female / Disabilities / Veterans

OSHA / ADA :

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer :