Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
ADA
E1. Ensure all claims are handled according to all internal operating and administrative procedures along with reviewing plan wording for each individual employer group, which should include the plan document, amendments, matrices and benefit summary.
E2. Monitor workflow of audits to ensure timely turnaround time. Identify the performance guarantee group’s audits to meet the strict guidelines for turnaround time.
E3. Maintain workload in accordance with the quality and production standards defined for the auditing team.
E4. Record results in the audit tool for monthly reporting. Partner with the supervisor to create and conduct training sessions for issues identified by the management team.
E5. Conduct one on one coaching with the claims team especially the trainee staff
E6. Provide recommendation for dollar authorization for claims team members based on audit stats and interaction with individual claim team members.
E7. Assist supervisor with specialized audits for the SOC process, carrier, vendor and employer audits as necessary.
E8. Maintain detailed knowledge of benefits, state regulations, federal guidelines and system upgrades.
E9. Review and provide expertise to the claims team with complex claim situation/issues by using all resources to render a sound decision.
E10. Utilize excellent written or verbal communication skills to liaise with clients, management, peers and other areas within the organization
E11. Manage the refund, void and stop payment process
E12. Provide guidance to the claims team with questions on all aspects of claims processing.
E13. Assist with system upgrade testing.
N14. Handle other duties as assigned
Education/Experience/Skills Requirements
Required Education:
HS/GED:
Required Experience:
5 years prior medical dental, vision, FSA and HRA claims processing experience. Preferred: Associate Degree
Required Knowledge/Skills:
1. Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding
2. Strong attention to details along with organizational skills
3. Excellent problem solving with the ability to work in a fast paced production environment
4. Excellent communication skills both verbal and written
5. PC navigation skills for Professional work environment
6. Basic MS Excel
7. Basic MS Word
8. Ability to use judgement to make sound decisions referencing all available resources
9. Ability to work independently and also as part of a team
Required Licenses/Certifications:
Problem Solving
Ability to research and seek assistance through all available resources, to ensure resolution on claim audits. Must be able to multi-task and follow up at appropriate intervals. Raise concerns to the management team on situations and/or issues in a timely manner.
Managerial/Supervisory Responsibilities
Does this Position have Supervisory Responsibility? No
Number of Emps Supervised:
Titles of Employees Supervised:
Financial/Budgetary Responsibilities:
Other Job Specifications:
External Contacts:
Working Conditions/Physical Demands:
Pay Range Minimum:
$21.96Pay Range Maximum:
$32.95Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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Skills Required
- High school diploma or GED
- Five years of medical, dental, vision, FSA, and HRA claims processing experience
- Comprehensive understanding of CPT, HCPCS, ICD-9, and ICD-10 medical coding
- Strong attention to detail and organizational skills
- Excellent problem-solving skills in a fast-paced production environment
- Excellent verbal and written communication skills
- PC navigation skills in a professional work environment
- Basic Microsoft Excel skills
- Basic Microsoft Word skills
- Ability to use judgment and available resources to make sound decisions
- Ability to work independently and as part of a team
- Associate degree
Highmark Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Highmark Health and has not been reviewed or approved by Highmark Health.
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Healthcare Strength — Medical, prescription, dental, and vision coverage are emphasized alongside 100% coverage for preventive exams, with onsite pharmacy access and fitness center availability at major campuses.
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Retirement Support — An employer‑sponsored 401(k) with a company match is highlighted, with AHN materials illustrating a 100% match on the first 4% plus an additional 1% employer contribution as an example within the enterprise.
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Wellbeing & Lifestyle Benefits — Wellness programs include stress‑management classes, health coaching, incentives for healthy activities, team‑member discounts, and volunteer incentives, with paid volunteer time also noted in the overall package.
Highmark Health Insights
What We Do
Highmark Health, a Pittsburgh, PA based enterprise that employs more than 40,000 people who serve millions of Americans across the country, is the second largest integrated health care delivery and financing network in the nation based on revenue. Highmark Health is the parent company of Highmark Inc., Allegheny Health Network, and HM Health Solutions. Highmark Inc. and its subsidiaries and affiliates provide health insurance to nearly 5 million members in Pennsylvania, West Virginia and Delaware as well as dental insurance, vision care and related health products through a national network of diversified businesses that include United Concordia Companies, HM Insurance Group, and Visionworks. Allegheny Health Network is the parent company of an integrated delivery network that includes eight hospitals, more than 2,800 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions in western Pennsylvania. HM Health Solutions focuses on meeting the information technology platform and other business needs of the Highmark Health enterprise as well as unaffiliated health insurance plans by providing proven business processes, expert knowledge and integrated cloud-based platforms. A national blended health organization, Highmark Health and our leading businesses support millions of customers with products, services and solutions closely aligned to our mission of creating remarkable health experiences, freeing people to be their best. Headquartered in Pittsburgh, we're regionally focused in Pennsylvania, Delaware, West Virginia and New York, with customers in all 50 states and the District of Columbia. We passionately serve individual consumers and fellow businesses alike. Our companies cover a diversified spectrum of essential health-related needs, including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative technology solutions. We’re also proud to carry forth an important legacy of compassionate care and philanthropy that began more than 170 years ago. This tradition of giving back, reinvesting and ensuring that our communities remain strong and healthy is deeply embedded in our culture, informing our decisions every day.
