Claims Processor II

MISSION Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors. VALUES HealthOne is guided by a cultural framework that embodies our values and drives our decisions. As a company our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. We fulfill our purpose by filtering our decisions through a PRIORITIES lens of asking, “Is what we are about to do ethical, empathetic, economical, and efficient?”. By caring for PEOPLE, we are welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done. HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals. JOB PURPOSE The Claims Processor II is responsible for accurate and timely processing of both professional and institutional medical claims pended for manual adjudication in assigned Workflow roles. The Claims Processor II will accurately interpret benefit and policy provisions applicable to fully-insured plan members and review claims to determine coverage based on contract, provider status, and claims processing guidelines. The incumbent must meet quality and productivity standards.

ESSENTIAL JOB DUTIES Reviews and adjudicates claims up to specified dollar limits Processes claims within performance guidelines of the department, including quality and timeliness Works with and understands Company benefit plans Understands provider contracts Examines and interprets all relevant documents included with the claims Responds to claim-specific questions, as applicable Partners with leadership on any questionable claim activity Understands logic of standard medical coding (i.e. CPT, ICD-10, HCPCS, etc.) Determines accurate payment criteria for clearing pended claims based on defined Policy and Procedures Researches claim edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for claims Works high volume of repetitive claims Identifies claims with inaccurate data or claims that require review by appropriate team members Contributes positively as a team player Completes special projects as assigned and supports other Claims Department team members in assigned projects Complies with all departmental and Company policies and procedures Maintains regular and predictable attendance Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice Works to encourage and promote Company culture throughout the organization Other duties as may be assigned QUALIFICATIONS High School Diploma or GED required Associates or Bachelor's Degree preferred A minimum of one year experience in claims processing required, must include Professional and Institutional processing; previous experience in medical billing and coding required if no claims processing experience Knowledge of ICD-10, CPT4, DRG, HCPCS codes, medical terminology, EDI and HIPAA protocols preferred Knowledge of UB and HCFA 1500 forms Certified Professional Coder (CPC) preferred Experience with Word and Excel PHYSICAL REQUIREMENTS Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required. BENEFITS 401K (4% Match, Immediate Vesting) Accident insurance Competitive salary Critical Illness Insurance Dental Insurance Employee Assistance Program Flexible Spending Account Health & Wellness Program Health Savings Account Life & AD&D Insurance Long Term Disability Medical Insurance Paid Time Off Pet Insurance Short Term Disability Vision Insurance PRE-EMPLOYMENT SCREENING Drug Screen and Background Check Required HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status or any other status protected by state or federal law.