Responsibilities
- Processes claims efficiently, meeting established benchmarks for productivity, accuracy, and turnaround time.
- Collaborates with cross-functional teams to resolve complex claims-related challenges.
- Adheres to federal regulations and accreditation requirements during claims adjudication.
- Delivers high-quality service by ensuring accurate claim payments and promptly addressing inquiries and concerns from members and providers.
- Builds collaborative relationships within the department to support effective communication and issue resolution.
- Applies department-specific protocols and guidelines when evaluating and processing claims.
- Identifies suspicious claim patterns and reports potential fraud to the designated compliance team.
- Maintains strict adherence to HIPAA regulations to safeguard patient health information.
- Supports organizational culture by embodying core values and service expectations.
- Provides exceptional service to both internal and external stakeholders.
- Fosters positive interactions through clear, professional, and timely communication.
- Proactively addresses customer service concerns, ensuring timely follow-up and resolution.
