Claims Adjuster (35406)

Duties and Responsibilities:

Responsibilities include, but are not limited to,

• Researches and interprets submitted requests to determine claim accuracy and the need for claim adjustment
• Responds to inquiry with clear explanation when claim is not adjusted
• Performs any necessary claim adjustments for overturned determinations directly in the HealthRules system.
• Requests appropriate adjustment via AWD to the Claims BPO
• Receives, tracks, completes and maintains the provider grids on a daily basis providing timely claims determination, adjustments where appropriate, and feedback to providers
• Partners with the Documentation Specialist to create desktop procedures
• Identifies areas of repetitive billing issues and rejected claim submissions to provide suggestions for provider education.
• Acts as a resource to Claims Production staff and other departments as needed
• Works in collaboration with internal departments to identify root cause of payment issues. Open JIRA tickets as needed Supports testing of new functions, features, system upgrades and new implementations
• Responsible for retroactive adjustment projects, as assigned.
• Responsible to perform special projects, and other duties as identified by management
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.