PURPOSE: Processing basic payments and/or claim denials for group health which includes medical, dental, vision, FSA, HSA, HRA and disability benefits; demonstrating the highest levels of customer service, technical skills and professionalism to ensure mutually rewarding and continued provider relationships.

ESSENTIAL FUNCTIONS:

• Examining and entering basic claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met.

• Processing claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.

• Approving, pending, or denying payment according to the accepted coverage guidelines.

• Identifying and referring all claims with potential third-party liability (i.e., subrogation, COB, MVA, stop loss claims, and potential stop loss files).

• Maintaining internal customer relations by interacting with staff regarding claims issues and research, ensuring accurate and complete claim information, contacting insured or other involved parties for additional or missing information, and updating information to claim file regarding claims status, questions or claim payments.

• Examining and entering complex claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met.

• Processing complex claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.

• Troubleshooting all claims with potential third-party liability, i.e. subrogation, COB, or MVA and stop loss claims and potential stop loss files.

• Approving, pending, or denying payment according to the accepted coverage guidelines.

• Assisting in training of new groups and new staff as needed; assisting the management team in problem resolution, planning, and overseeing workflows; testing and preparing documentation and updating current documentation, as well as providing suggestions and recommendations to improve workflows and departmental efficiencies

Qualifications:

• High School diploma or GED required

• Ability to work remotely

• Good attention to detail

• Must be able to work in a high-performance environment that changes often

• Experience in navigating multiple systems using dual monitors

• 2-3 years Claims processing or directly related work experience.

• Knowledge of medical terminology, CPT-4, ICD-9, ICD-10, HCPCS, ASA and UB92 Codes, and standard of billing guidelines required.

• FACETS Experience preferred

• Must have Medicaid knowledge

• Audit experience preferred.

• Proficient in Microsoft Office – Excel, Word, and Outlook

Cognizant will only consider applicants for this position who are legally authorized to work in the United States without requiring company sponsorship now or at any time in the future.