Hospital Claims Adjuster

The Hospital Claims Adjuster is responsible for the adjusting of hospital risk claims, in accordance with outside regulations and the contractual obligations of the Health Plans and/or the Hospitals/IPAs. Research, reviews, and contacts provider services for problem claims and issues, as needed. Suggests process improvements to management and is a resource of information to all staff.

Duties and Responsibilities

· Accurately review all incoming adjustment requests to verify necessary information is available.

· Meets production and accuracy standards established by claims management.

· Adjust claims in accordance with departmental policies and procedures and other rules applicable to claims.

· Coordinate resolution of claims issues with other Departments.

· Assist Providers and other Departments in claims research.

· Review and adjudicate web portal inquiries.

· Assist in training claims personnel when issues are identified.

· Promote a spirit of cooperation and understanding among all personnel.

· Attend organizational meetings as required

· Adhere to organizational policies and procedures.

· Performs other tasks as assigned by Claims Leadership.

· Adhere to MedPOINT Management’s core value: Accountability, Community, Celebration, Integrity, Innovation & Collaboration

Minimum Job Requirements

· High School Graduate

· Minimum 1 year experience as a Claims Examiner II

· One year experience with Hospital/Facility risk claims

Skill and Abilities

· Knowledge of DOFR interpretation and the adjudication of hospital risk claims.

· Ability to get work done efficiently and within timeliness guidelines.

· Experience in a managed care environment preferred.

· ICD-9 and ICD-10 and CPT-4 coding knowledge preferred.

· Must be detail oriented and can work independently

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