QUALIFICATIONS:

Education Level: High School Diploma or GED.
Experience: 5 years claims experience required.
Preferred Qualifications: 5 or more years claims processing, billing or medical terminology experience.

KNOWLEDGE, SKILLS AND ABILITIES (KSAS)

• Strong communication skills both written and verbal.
• Excellent analytical skills.
• Advanced level reading comprehension skills with ability to apply information read to process.
• Knowledge of insurance concepts and products.
• Knowledge and understanding of claims systems and processes.
• Skill in completing assignments accurately with attention to detail.
  Salary Range: $41,904 - $76,824
  Salary Range Disclaimer
  The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate’s work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case’s facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
  Department

Uses expert knowledge of systems to process all types and dollar level of claims and to identify key elements and processing requirements based on diagnosis, provider, medical policy, contracts, policies and procedures. Uses broad based product and multiple system knowledge to ensure timely considerations are generated.

• Does extensive research of procedures. May also apply training materials, emails and medical policy to ensure claims are processed correctly. Utilizes the quality team for assistance on unclear procedures and/or difficult claims and receives coaching from leadership. Ongoing developmental training to perform daily functions.
• Completes productivity data daily that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design, financial planning, etc.
• Provides leadership to less experienced staff through mentoring or training. Assists in training class

PURPOSE:

Under general supervision, reviews and adjudicates complex paper/electronic claims. Determines proper handling and adjudication of claims following organizational policies and procedures. Provides leadership to less experience staff through mentoring and training.

ESSENTIAL FUNCTIONS:

Uses expert knowledge of systems to process all types and dollar level of claims and to identify key elements and processing requirements based on diagnosis, provider, medical policy, contracts, policies and procedures. Uses broad based product and multiple system knowledge to ensure timely considerations are generated.

• Does extensive research of procedures. May also apply training materials, emails and medical policy to ensure claims are processed correctly. Utilizes the quality team for assistance on unclear procedures and/or difficult claims and receives coaching from leadership. Ongoing developmental training to perform daily functions.
• Completes productivity data daily that is used by leadership to compile performance statistics. Reports are used by management to plan for scheduling, quality improvement initiatives, workflow design, financial planning, etc.

• Provides leadership to less experienced staff through mentoring or training. Assists in training class.

• • Assists Customer Service Reps by providing feedback and resolving issues and answering basic processing questions.