Point32Health

Insurance

• Process complex claims: fully research and resolve complex issues and problem codes for proper adjudication
• Manually apply specific product or benefit rules to claims and manually calculate/apply pricing when necessary
• Ensure claim payment correctly reflects Point32Health’s status as primary or secondary payer through coordination of benefits
• Determine member eligibility and verify services are allowable under member benefit plan and required authorizations/referrals/pre-registrations
• Process complex claim adjustments: review requests, determine need for re-adjudication, research provider payment inquiries
• Examine and correct/update claim data; prepare and enter adjustments with appropriate back out and adjustment reason codes
• Assist partner departments and promptly research and resolve escalated issues from other departments and management
• Monitor pending claims and adjustments daily to ensure timely release for adjudication and meet quality/production standards
• Participate in identifying opportunities for process improvements and serve as SME for documentation, projects, and testing
• Act as role model and mentor to core claims processors and provide back up support to other department areas
• Responsible for timely and accurate processing of Member Reimbursements and comply with department/company guidelines and policies

Claims Specialist