• Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines.


• Process claim payment thoroughly, attend all training, and refresher courses.    


• Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes. 


• Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing.


• Establish and maintain COB files, determine other coverage according to regulatory and plan requirements.


• Applies COB payments for final claim payment.


• Research and determine proper CPT procedure and ICD-10 Diagnosis Codes.


• Research and respond to written correspondence from participants, providers, and local unions/employers.


• Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines.   


• Work effectively to achieve at a minimum production, quality, and accuracy standards.


• Display maturity, composure and ability to operate under stress conditions.


• Follow department policy and procedures distributed.


• Attend mandatory department meetings as scheduled.


• Assist other department areas as required dependent on workload and inventory needs.


• Excellent organization and assignment management skills.


• Clear communication with internal and external customers.


• Ability to Navigate in external network pricing platforms.


• Ability to prioritize workload and adhere to network administrative agreements.


• Maintains professionalism at all times.


• Perform other duties as assigned.