Humera - Administrative and Professional Staffing

Claims Processor III

Minnetonka, MN, United States
Contact For Rate
Sep 13, 2017
Sep 16, 2017
Job Type
Employment Status
Full Time
Humera is seeking multiple Claims Processor III candidates for our client, a major health insurance provider, in Minnetonka, MN. These are CONTRACT TO HIRE opportunities with a great company in the West Metro.

The Claims Processor III is the expert resource in terms of claims system capabilities, recommended system application and the implementation of benefits and reimbursement policies for all business segments. They provide content expert training to claims processors, internal customers on the policies administrated by Health Rules or iCES. They also work closely with the Coding Consultants, Auditors, Claims Management Teams and the Operations Analysts to ensure proper system implementations and claims processing.

This individual will be responsible for processing complex claims and will serve as the first point of contact “expert” for claims processing issues related to Health Rules, iCES,deductible/out-of pocket accumulators, provider claims histories, check void/replacement, based on a variety of inter and intra-departmental needs. In addition, the Claims Processor III will assist in the training and auditing of new hires and will serve as a“tester and auditor” for new Health Rules enhancements. The Claims Processor III is expected to provide recommendations for claims enhancements or process improvements for claims processing. Minimal travel will be required each month.

The Claims Processor III is also responsible for reviewing Policy and Procedure documents to ensure they are current and accurately reflect claims processing requirements. This person works with managers within Operations as well as I.T., Payment Intent, Network Management, Internal Audit, and Finance related to claims processing or implementation of new products or system enhancements.

Claims Processor and Claims Expert Resource 60%
  • Process assigned claims timely and with a high degree of accuracy
  • Work with the content experts in Provider Services, Customer Service, Coding/Auditing and Operations Administration, etc to gather information, define resolutions in order to process claims and implement or redefine processes, policies or procedures
  • Coordinate cross-functional meetings to identify root cause of issues
  • Manage the Claims Questions and Customer Service Request issues mailbox questions in a timely manner
  • Perform research and develop innovative methods for automating claims reporting or processing methodologies
  • Serve as a resource for complex claims issues and solve for root causes
  • Analyze, map and document current workflow and recommend process improvements by working with the appropriate internal and external departments to implement these process improvements
  • Requires the ability to identify and recommend opportunities for system efficiencies through automation. This will require an understanding of the current systems infrastructure and become a subject matter expert on business functions having significant financial impact.
  • Reviewing policies and procedures and making recommendations for improvement
  • Acting as a consultant for policy and procedure development
  • A working understanding of health plan operational flows, reimbursement methodologies, system capabilities for contracting automation, and an ability to work with staff to ensure operations support accuracy of provider payments
  • Act as an internal consultant to customers who are in need of identifying process improvement opportunities within their departments
Participation on various work groups and assumes leadership/ownership of special projects 20%
  • Participate on various workgroups throughout the organization; such examples are: Accumulator alignment between Health Rules and Med-Impact, Provider claims history reporting; EOB/PRA adjustments; assumes Lead or Analyst Responsibilities in their absence
Auditing and training of new hires or system enhancements 15%
  • Train and review claims processed by new hires internal or external to claims; provide timely feedback
  • Report training/audit results to Supervisor/Manager
  • Audit and test system enhancements; provide audit results
  • Document process improvement recommendations
  • Report overpayments or suspected fraudulent behavior
Policy and Procedure Management/ Health Rules System consultation 5%
  • Work with the Claims and Quality Managers to ensure policies and procedures are updated in a timely manner

  • High School degree, or equivalent
  • 4 years or more direct claims processing experience with a minimum of 1 year of direct claims processing experience within Health Rules
  • Must have strong written and verbal communications skills, meeting facilitation skills, interpersonal skills, attention to detail, organizational and prioritizing skills
  • Knowledge and understanding of products
  • Process improvement experience preferred
  • Understanding of provider contracting and claims processing
  • Detail oriented/analytical thinking, creative - thinks outside the box
  • Strong project management skills and extensive data analysis skills
  • Ability to identify trends and clearly articulates them
  • Understanding of Health Rules claims processing and an understanding of reimbursement methodologies
  • Written and verbal communications
  • Positive and respectful
  • High ethical standards
  • Self-motivated
  • Possess personal integrity
  • Able to collaborate with a team
  • Sound technical skills, expert analytical ability, and good judgment

    Monday - Friday 8AM - 5PM

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