Claims Processor/Adjudicator - remote opportunity

The Claims Processor/Adjudicator will review claims for completeness and validity based on verification of eligibility and interpretation of contract benefits and process accordingly.

Essential Duties and Responsibilities:

• Review claims for correct internal data entry and make necessary changes.
• Review claims for correct provider coding information regarding appropriateness of reported services and billing practices.
• Request additional information needed to complete adjudication of claim-e.g., records and/or x-rays, clarification of submitted billing information.
• Review claims for necessity, limitations and exclusions based on claim policies and procedures.
• Determine and enter appropriate benefit/adjudication coding based on subscriber’s plan benefits-e.g. explanation codes, denial codes, pricing structure, accumulators, system overrides.
• Document subscriber, provider and group files when appropriate for audit trail.
• Assist internal associates with claims related questions and issues.
• Identify reoccurring problems and provide feedback to management to effect change.
• Conduct claim specific research to resolve outstanding provider issues
• Research claim issues to identify root cause and determine corrective action to resolve issue, communicate findings, document findings for future use
• Master competency to process OON and MR1 claim queues.

• High school diploma or equivalent.
• Two or more years of prior experience in health insurance claims processing preferred.  Medicare/Medicaid claims experience a plus!
• 2+ years of claim processing experience in HCFA 1500.
• Strong analytical and problem solving skills.
• Excellent communication skills (oral, written, and presentation).
• Ability to manage workflow and meet deadlines on a consistent basis.
• Ability to use Microsoft Office software proficiently.
• Individual must possess proven organizational and interpersonal skills.
• Individual must possess the ability to collaborate with others and work effectively within a team environment.
• Knowledge of medical terminology.
• Ability to interpret varied insurance contracts, both member and provider.
• Ability to work independently and as part of a team to accomplish department goals.
• Ability to handle varied workload.
• Knowledge of ICD-10 and CPT coding a plus!

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The hourly wage for this opportunity is $15.90-18.50. Compensation depends on several factors: qualifications, skills, competencies, and experience.

Tivity Health offers a robust benefits package, which includes a competitive salary, company bonus potential, medical, dental, vision, 401k with match, generous paid time off, free gym membership to over 11,000 fitness locations in the US, and other great benefits.