Claims Processor

GENERAL FUNCTION

The Claims Processor accurately and efficiently processes claims from source documents, maintaining compliance with the insurance plan requirements and with high regard for adhering to goals for quality and claims production rates. Also performs other simple processes requiring a basic knowledge of claims adjudication.

MAJOR DUTIES AND RESPONSIBILITIES

1. Efficiently and accurately processes a variety of vision insurance claims or adjustments.
2. Determines any special plan requirements prior to billing.
3. Reviews claims before entry for completeness and compliance with business requirements.
4. Effectively and accurately reviews images and transcribed data in the Vidado portal in preparation for auto adjudication.
5. Participates on special project initiatives, including rework efforts as needed.
6. Understands and quickly operationalizes processing changes resulting from new plans, benefit designs.
7. Maintains compliance with HIPAA guidelines and regulations.
8. Works with supervisor and co-workers to provide a high standard of customer service and communication with key customer interfaces that include Account Managers, Operations, Information Systems, Client Representatives and leadership team.
9. Partners with the Provider Relations team by providing information that is necessary to properly train the stores, providers and field management.
10. Contacts stores or providers (when necessary) to obtain additional information or follow up on claims.

BASIC QUALIFICATIONS

1. High School diploma or equivalent work experience
2. 1+ year(s) of data entry experience

PREFERRED QUALIFICATIONS

1. Bachelor's degree
2. Claims processing experience
3. Strong customer service focus
4. Good verbal communication skills
5. Good written communication skills
6. Able to quickly grasp and retain information and concepts
7. Able to multi-task and prioritize issues
8. Strong attention to detail
9. Knowledge of Medicare/Medicaid business
10. Understand and honor high level of confidentiality
11. Knowledge of vision benefits and/or insurance industry
12. Proficient in Microsoft Word, Excel and Access
13. Working knowledge of interface systems such as Facets, EyeNet, and ExClaim