Claims Adjudicator Sr

Department: UHC: Managed Care

Job Summary: The Claims Adjudicator Sr is responsible mentoring and training Claims Adjudicators. The Lead will also analyze and process professional and hospital HMO Risk claims in accordance with the managed care contract provisions in an accurate and timely manner. Responds to questions from other adjudicators and processors. Verifies system assigned risk pool determination in accordance with the Division of Financial Responsibility matrix. Assists Director in creating, reviewing, and enhancing policies and procedures governing full risk claims processing on an annual basis or as needed. Assists other adjudicators and/or examiners as needed in order to assure that claims are completed within standards. Performs other duties as needed.

Education and Experience: High School Diploma or GED required. Associate's Degree preferred. Minimum five years managed care claims processing experience with professional and/or institutional claims required.

Knowledge and Skills: Extensive experience in health insurance claims processing, HMO claims or managed care environment is required, in-depth knowledge of medical billing and coding, knowledge of health insurance, HMO and managed care principles. Claims Payment System including Claim Hierarchy Categories, CPT, ICD-10, HCPCS, UB-04. Knowledge in UB and HCFA-1500 Insurance Claims, reading and interpreting Contracts and DOFR. Understanding of all CMS guidelines and regulations in relation to Claims Processing and Payments. Able to read; write legibly; speak in English with professional quality; use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate/troubleshoot basic office equipment required for the position; Able to relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.

Licensures and Certifications: Valid California Driver's License required at time of hire.