Position Description

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NON-EXEMPT POSITION DESCRIPTION

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Position: Claims Specialist - 8 Job Code: 53001E Min Salary: 28000
Reports To: Date: 7/20/2012    
Division: HA Claims Operations (9910) Company: HEALTH ADVANTAGE    

Position Specific Requirements: None

Job Summary
The Claims Specialist is responsible for accurate and timely adjudication of medical claims. This may include additional investigation or communication in order to obtain necessary information to complete the claim. The Specialist will be subject to divisional standards of quality and productivity.

Nature & Scope
• ENVIRONMENT

The environment is one of teamwork, in which all team members work together in order to provide excellent service through the proper/timely adjudication of claims. Outside issues affecting this division and position include peak filing seasons, systems down time, inclement weather, holidays and absenteeism. All directly affect the volume of work for each Specialist.

• WORKFLOW

Medical claims submissions may be submitted through the mail, providers, and plan participants. Claims submissions may also be received by electronic media from providers. Pended claims reports will be reviewed based on department guidelines in order to maintain divisional standards of claim processing timeliness.

Normal processing includes data entry of the claim, the review and interpretation of contract benefits and edit/audit resolution, claim payment and routing claims to other areas. Development includes telephone calls to providers and internal personnel, generating correspondence, and completing forms to obtain information necessary for claim adjudication. Medicare primary claims require numerous development steps in order to interpret Medicare's payment, coordinate benefits and make the appropriate payment. Processing of some claims may require reviewing letters from physicians to determine benefit eligibility.

• GUIDANCE

Corporate and professional books guide the activities of the Claims Specialist and manuals including the Processing Manual located on TextBOOK, Diagnosis book and the ICD9, CPT4 and HCPS Procedure Codebook. System edits, flags and numerous claim procedure memos also guide the process. Self-guided decisions are based on knowledge obtained from the initial training course, on-the-job training and continuing education (i.e. medical terminology, etc.) The Specialist receives direction from the supervisor and/or manager.

• CHALLENGES

Continually changing processing procedures, benefits and systems modifications represent the most difficult challenges for this position. The Specialist must be knowledgeable of and have the ability to access all relevant mainframe systems and screens in order to process claims accurately. The Specialist is challenged to process claims in an accurate and timely manner in order to meet government, corporate and national standards (MTM) while maintaining acceptable performance levels based on established department standards for production and quality.

• INTERFACES

This position may interface regularly with the following:

External: Providers and group contacts- development of claims information.
Internal: A broad cross section of internal departments, including the regions.

• AUTHORITY

This position has the authority to develop, process (pay) and refer claims to management or other divisions. This position also has the authority to make suggestions for improvement to the claims processing and development procedures.


Minimum Job Requirements

1. High School Diploma, College courses preferred

2. Office experience, i.e. claims processing/health insurance, medical office or college (48 Semester hours) or other equivalent, certification with emphasis in anatomy, medical terminology, math, biology, etc.

3. Complete claims assessment proficiency

5. Typing skills or Alphanumeric Data Entry

6. Competent Communication Skills and interpersonal skills

Requirements - Grade 9

  • Must successfully met criteria and performance standards for a Grade 8 for at least nine(9) consecutive months after successfully completing training
  • Must meet corporate policy on Tardies and Unscheduled Absences
  • Has not been placed on any written warning in the previous six (6) months.
  • Supervisor has received no consistent and substantiated negative feedback from internal or external customers within the previous six(6) months
  • Demonstrates analytical skills
  • Participates in special projects

Performance

Consistently meets or exceeds performance expectation for attendance, production, and quality.

Requirements - Grade 10

  • Must successfully met criteria and performance standards for a Grade 9 for at least nine(9) consecutive months after successfully completing training
  • Must meet corporate policy on Tardies and Unscheduled Absences
  • Has not been placed on any written warning in the previous six (6) months.
  • Supervisor has received no consistent and substantiated negative feedback from internal or external customers within the previous six (6) months
  • Demonstrates analytical skills
  • Has participated in at least 2 special projects

Performance

Consistently meets or exceeds performance expectation for attendance, production, and quality.

Requirements - Grade 11

  • Must successfully met criteria and performance standards for a Grade 10 for at least nine (9) consecutive months after successfully completing training
  • Must meet corporate policy on Tardies and Unscheduled Absences
  • Has not been placed on any written warning in the previous six (6) months.
  • Supervisor has received no consistent and substantiated negative feedback from internal or external customers within the previous six(6) months
  • Demonstrates analytical skills
  • Has participated in at least 3 special projects

Developmental - Grade 11

  • Must complete the IDP course as well as submit an IDP to supervisor
  • Must complete the following Blue and You University courses:

1.  Leading through Change: LEAD 0147

2.  Excellence in internal Customer Service: CUST 0141

3.  Other Courses as approved or recommended by supervisor

Performance

Consistently meets or exceeds performance expectation for attendance, production, and quality

Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1. Process Claims

• Data entry claims
• Edit/audit resolution
• Review, interpret and apply benefits
• Determine eligibility
• Identify claims processing problems

2. Development

• Write memos and complete forms
• Consult internal staff and medical providers
• Research claim problems via systems and manuals

3. Perform other duties as assigned which may include but not limited to providing back up support for other areas such as Development and/or Submission; special assignments to other areas needing support and special projects as directed by the supervisor and/or manager.


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Employee Benefits

Our very competitive package of Employee Benefits includes everything from tuition reimbursement to 401(k) savings plans.