Through comprehensive assessment and analysis, adjudicates managed healthcare claims/bills, authorizations and referrals, for payment or denial within contract agreement and/or regulatory requirements. Performs these duties using industry standard knowledge of managed healthcare claim/bill payment processing and medical regulations, verifies and updates relevant data into various computerized internal and external systems.

• For all lines of business analyze claim holds/pends, research and track required claim information to adjudicate professional and hospital claims/bills.


• Proactive and or responsive outreach to provider, members and other customers that could include phone calls, emails or other methods as needed.


• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.


• Provides input to supervisor and training and development team regarding training and educational tools to enhance department production and processes.


• Proactively communicate with internal departments as appropriate to resolve claims issues promptly.


• Provides assistance to prepare materials as needed to the leads, supervisors and managers for external audits.


• Communicate problems and/or trends to leads and management. Understand and apply county, state and federal regulations.


• Other duties as assigned within department job functions.

• Minimum three (3) years of claims adjudication experience required.

• High School Diploma or General Education Development (GED) required.

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• Customer service experience.
• Basic PC skills required.
• Working knowledge of Microsoft Word.
• Ability to work in a in a Labor Management Partnership environment.
• Ability to understand and meet customer needs in a claims setting.
• Ability to apply procedures, practices and methods used in claims processing.
• Skills in analysis, interpretation and application of procedures, practices and methods used in claims adjudication without direct supervision or oversight.

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