Claims Adjuster

Job Summary:

Reviews claims and makes payment and benefit determination. Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required.

Essential Responsibilities:

• Reviews claims and makes payment determination with authorization limit to $9,999 per claim.
• Conducts research regarding medical appropriateness, coordination of benefits issues, fraud and abuse, and third party liability.
• Checks with Lead and Supervisor for any claim exceeding $9,999.
• Provides input to Supervisor regarding trends related to training, education to enhance department production and processes.
• Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA.
• Proactively works to ensure claims are review & processed timely.