SSM Health Hiring For Claims Representative Associate, Health Plans at Madison, WI, United States Full Time

Job Description

Responsible for providing accurate and timely claims processing of claims in order to provide excellent service to plan members and providers. Requires knowledge of the variety of health plan products, medical terminology, and various benefit options which impact claims processing. Reviews claims for accuracy and completion and to obtain missing information as necessary. Determines claims coverage by examining company records, confirm claims payment amounts, and submits claims for payment in a timely manner consistent with expected turnaround times.
PRIMARY RESPONSIBILITIES

• Processes claims in accordance with the claims processing system and other department guidelines.
• Researches claims accounts; reverse and reprocess claims as necessary.
• Reviews provider status to determine participating/nonparticipating, primary, referral and correct reimbursement level, which may include re-pricing.
• Processes provider appeals of claim determination to resolve or escalate as appropriate.
• Stays abreast of related regulatory, compliance and departmental updates to meet departmental metric requirements.
• Participates in team activities to identify problems and improve work processes and systems.
• Perform other special assignments as requested.

EDUCATION

• High school diploma or equivalent

EXPERIENCE

• One year of insurance experience with claims processing or related area

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.