Claims Adjudicator III

Job Summary:

The Claims Adjudicator III is responsible for processing a wide variety of claims within department standards and act as a technical resource to all Claims team associates.

Essential Functions:

• Process a wide variety of claims (at all pend levels) within department standards
• Research and resolve claims with “error messages” by researching and correcting codes, units, etc.
• Constructively interact with other departments such as Enrollment, Medical Management, Provider Operations, and Configuration to facilitate claim processing
• Recognize claims for possible fraud, waste, or abuse
• Process exception claims within timely filing limits
• Act as a technical resource to all Claims team associates by reviewing claims, training, providing job shadowing and answering questions
• Identify potential process improvements and participate and/or facilitate related initiatives
• Professionally and competently serve as Subject Matter Expert on claims processing both internally within Claims Department and other CareSource departments and externally as needed (regulators, auditors, etc.)

• Perform any other job duties as requested

Education and Experience:

• High School Diploma or equivalent required
• Post-secondary academic coursework, degree, or certification in Healthcare related field is preferred
• Minimum of three (3) years of health insurance claim adjudication experience is required
• Medicaid managed care claim adjudication experience is preferred
• One (1) year recent CareSource Claim Adjudication experience is preferred

Competencies, Knowledge and Skills:

• Intermediate computer skills such as Excel, Word and Outlook
• Medical terminology; CPT-4 and ICD-10 coding knowledge required
• Written and oral communication skills
• Ability to work independently and in a team environment
• Attention to detail
• Ability to remain focused in a production environment
•  Proven knowledge of multiple products and reimbursement methodologies
• Knowledge of Medicaid
• Critical Listening and Thinking Skills
• Training/teaching skills
• Time management skills
• Customer service oriented
• Decision making/problem solving
• Leadership skills

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Flexibility to meet training schedules within standard scheduled hours
• Some weekends may be required based on business needs

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business