Claims Adjudication
2 days ago
Key Responsibilities:
- Adjudicate medical, dental, and vision claims using the Facets platform.
- Review and analyze claims for eligibility, provider contracts, coding accuracy, and payment rules.
- Ensure timely and accurate processing of claims per regulatory and organizational standards (e.g., CMS, HIPAA).
- Identify discrepancies or issues in claims data and take corrective actions.
- Apply plan benefit designs and provider fee schedules during claim review.
- Collaborate with cross-functional teams including customer service, provider relations, and medical management.
- Participate in audits and quality checks to ensure process accuracy.
- Maintain confidentiality and compliance with data protection standards.
Required Skills & Qualifications:
- 1 to 3 years of experience in healthcare claims adjudication.
- Hands-on experience with Facets claims processing system is mandatory.
- Knowledge of CPT, ICD-10, and HCPCS coding standards.
- Familiarity with Medicare/Medicaid or commercial insurance claim guidelines.
- Strong analytical and problem-solving skills.
- Proficient in MS Office applications (Excel, Word, Outlook).
- Excellent written and verbal communication skills.
- Ability to work independently as well as in a team-oriented environment.
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