Claims Adjudicator II, Fully Remote
Claims Adjudicator II, Fully Remote
UNITE HERE HEALTH
Aurora, IL
See who UNITE HERE HEALTH has hired for this role
The Claims Adjudicator II position is fully remote. The Adjudicator will receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day to day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries.
Essential Job Functions And Duties
- Screens claims for completeness of necessary information.
- Verifies participant/dependent eligibility.
- Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents.
- Codes basic information and selects codes to determine payment liability amount.
- Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit. requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered.
- Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers.
- Handles the end to end process of Medicare Secondary Payer (MSP) files.
- Processes Personal Injury Protection (PIP) claims.
- Requests overpayment refunds, maintains corresponding files and performs follow-up actions.
- Handles verbal and written inquiries received from internal and external customers.
- Processes Short Term Disability claims.
- Adjudicates claims according to established productivity and quality goals.
- Achieve individual established goals in order to meet or exceed departmental metrics.
- 3 ~ 5 years of direct experience minimum in a medical claim adjudication environment
- Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
- Working knowledge and experience in Subrogation and its related processes
- Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
- Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes
Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a full-time remote position.
We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).
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Seniority level
Mid-Senior level -
Employment type
Full-time -
Job function
Finance and Sales -
Industries
Hospitals and Health Care
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