Claims Adjudicator II

UNITE HERE HEALTH

serves 200,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The Claims Adjudicator II position will receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes. This position utilizes multiple systems in order to perform the day-to-day functions of processing medical, disability, vision and dental claims, as well as, provider and member driven inquiries.

ESSENTIAL JOB FUNCTIONS AND DUTIES

Screens claims for completeness of necessary informationVerifies participant/dependent eligibilityInterprets the plan benefits from the Summary Plan Description (SPD)/Plan DocumentsCodes basic information and selects codes to determine payment liability amountEvaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care renderedDetermines the need for additional information or documentation from participants, employers, providers and other insurance carriersHandles the end to end process of Medicare Secondary Payer (MSP) filesProcesses Personal Injury Protection (PIP) claimsRequests overpayment refunds, maintains corresponding files and performs follow-up actionsHandles verbal and written inquiries received from internal and external customersProcesses Short Term Disability claimsAdjudicates claims according to established productivity and quality goalsAchieve individual established goals in order to meet or exceed departmental metrics

ESSENTIAL QUALIFICATIONS3

~ 5 years of direct experience minimum in a medical claim adjudication environmentWorking knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefitsExperience with eligibility verification, medical coding, coordination of benefits, and subrogation and its related processesExperience with medical terminology, ICD10 and Current Procedural Technology (CPT) codesFluency (speak and write) in Spanish, preferred Salary range for this position: Hourly $20.36 - $24.97. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) Fully Remote, after 1-week training onsite in Oak Brook, IL. (Travel and Lodging paid for by UHH)We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).#LIRemote