Using a PC /Microsoft Window environment, adjudicates claims with the aid of the Facets, PnS (Networx) and Macess Systems. Reviews and ensures the accuracy of all provider, member and claim line information for all claims for which the examiner is responsible. Reviews and ensures the accuracy of all changes to claim line information based on information received from other departments and in accord with available benefit information. Is responsible for the timely and accurate adjudication of claims that are suspended to other MVP departments for benefit and/or authorization determination. Meets or exceeds department quality and work management standards for claims adjudication. Successfully completes a course of comprehensive formal training in all areas of benefits determination, system navigation, and MVP policy. Suspends, investigates and resolves claim issues by coordinating with appropriate departments, based on criteria set by those departments. Handles inquiries regarding suspended claims from other departments and identifies trends in suspensions based on these inquiries and other feedback. Reports same to Claims Operations Supervisor. Keeps abreast of all benefit changes. Provides ongoing feedback to the senior or Claims Operations Supervisor to insure all appropriate personnel are kept informed. Performs other duties as assigned.
Minimum Education: 2 year college degree or directly related business experience.
Minimum Experience: Previous claims processing/health insurance experience required.
" Independent Adjusters License may be required. (If not certified when hired or transferred into position, may need to obtain in the next IAC training class.)
" Strong communication skills;
" Organizational skills and attention to detail;
" Strong PC skills required, Microsoft Windows experience highly desired
MVP Health Plan covers about 650,000 most valuable people. Also known as MVP Health Care, the company provides health insurance and employee...