Under general supervision, investigates claims liability and determines the extent of liability on a submitted claim for a specific individual. Accurately processes the claim according to the policies or contracts that exist, within the departmental time frames and standards, and establishes reserves for claim liability.
Key Responsibilities Intro
Relying on limited experience and knowledge, this role is responsible for accomplishing the following assignments. These assignments are varied in nature.
Review and interpret employer plans of health coverage and excess insurance policy to individual claims.
Audit submitted claim documents for sufficient data, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability
Communicates in writing and verbally with third-party administrator (TPA)/client, as needed, to resolve claim processing issues.
Set claims reserves and adjusts as needed. Keep the reserves current.
Authorize checks for amount of liability and communicate to TPA/client reasons for any amounts not covered by excess policy.
Refer large-dollar claims and trigger diagnosis to preliminary claims and case management departments.
- Follow work plans, established timelines, and predefined goals for assigned work.
- Meet commitments on deadlines.
- Communicate activities, results, and observations with employees and management as appropriate.
- Identify areas for improvement in existing business practices.
- Perform work thoroughly in a cost-efficient manner and at a high productivity level.
Business Controls and Policies
- Comply with all corporate policies and procedures.
- Report any breakdowns in controls to management.
- Conduct all activities in a safe manner.
- No people management responsibility.
Position Knowledge, Skills, and Requirements
Min/Preferred Education Level Description
4 Year / Bachelors Degree
Business Administration, a related field, or the equivalent education and/or experience
Certifications, Licenses, and Designations
Years of Experience Area of Experience
relevant and progressive professional experience
Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPPA
Ability to read and interpret documents such as Plan of Benefits, claim reports, and procedural manuals
Possess and have ability to apply broad knowledge of principles, practices, and procedures
Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy
Exceptional organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously
Knowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company’s business to proactively respond to changing business environment
Intermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)
Working Conditions and Physical Demands
Additional Working Conditions and Physical Demands
Overtime hours may be required to fulfill job responsibilities
May be required to remain stationary for extended periods of time
May be required to move up to 10 pounds
Must be able to operate a computer and other devices
Close vision and ability to adjust focus, such as required to read a computer screen
Travel Required Passport Required Driver's License Required
Occasional travel (up to 10% of time)
This document is intended to describe the general nature and level of work being performed, and is not to be construed as an exhaustive list of all responsibilities, duties and skills required for the job.
TMHCC will consider all requests for reasonable accommodation as outlined in the Employee Handbook. Management may, at its discretion, assign or reassign duties and responsibilities to this job at any time.