POSITION SUMMARY

The Claims Processor is the entry role for our claim processing team. This person will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client’s customized plan(s).

ESSENTIAL FUNCTIONS:

• Process a minimum of 1,200 medical, dental, and vision claims per week while maintaining quality goals.
• Read, analyze, understand, and ensure compliance with clients’ customized plans
• Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
• Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
• Review, analyze and add applicable notes in the QicLink system.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Analyze claims for billing inconsistencies and medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Review Workflow Manager daily to document and release pended claims, if applicable.
• Review Pend and Suspend claim reports to finalize all claim determinations timely.
• Assist and support other Claims Specialists as needed and when requested.
• Attend continuing education classes as required, including but not limited to HIPAA training.

EDUCATION:

• High School Graduate or equivalent required.

EXPERIENCE & SKILLS:

• Applicants must have a minimum of two (2) years of medical claims analysis experience (Medicare/Medicaid does not count towards the experience) required.
• Prior experience with a Third-party Administrator (TPA) is highly preferred.
• Applicants must have knowledge of CPT and ICD-10 coding.

• Applicants must have strong analytical skills and knowledge of computer systems.
• Applicants must demonstrate the desire to assist the Team with exceeding all established goals.
• Prior experience with dental and vision processing is preferred, but not required.

COMPETENCIES

• Communication
• Customer Focus
• Accountability
• Functional/Technical Job Skills

PHYSICAL DEMANDS:

• Office setting and ability to sit for long periods of time.

WORK ENVIRONMENT:

• Remote

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensation is not limited to base salary.  Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life & Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.

Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time.  All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process.  It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.