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Claims Adjudicator - Paramount - Remote

Toledo, Ohio
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Description

ProMedica’s health plan, Paramount Insurance, offers health insurance products across six Midwest states. Paramount is an Ohio-based health insurance company, headquartered in Toledo. The organization has more than 800 employees dedicated to serving their health plan members.

Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality

In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers’ compensation, as well as vocational rehabilitation, life-care planning and wellness.

As a part of ProMedica, Paramount is driven by ProMedica’s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website. http://www.paramounthealthcare.com.

Basic Purpose:

Perform adjudication as assigned on claims that require multiple pend code resolution , application of manual pricing methods for hospital , medical and/or ancillary services for all product lines to ensure superior quality and member and provider satisfaction. Success in this position will be based on the individual’s ability to effectively prioritize work, identify and resolve complex concerns in a professional manner, and work in a team environment to achieve a common goal.

Primary Duties:

  • Promptly process to meet Plan standards, prompt pay standards, and ensure that any governmental regulatory agencies and group guarantees are met. Promptly adjudicate claims from assigned workflow queues, as well as working “pended to desktop” claims. Apply bundling logic as determined by the current software. Make appropriate determinations on complex pended claims to reflect approval or denial within Plan established timeframes.
    • Production 150-160 claims per day
    • Pended claims – no more than 2% over 30 days.                                           
  • Promptly and accurately apply bundling logic as determined by the current software programs to ensure appropriate payment avoidance.
  • Accurately process claims and apply appropriate processing procedures to ensure established accuracy thresholds are met. Is responsible for to follow CP-14 as it relates to QI slips
    • Payment 98%
    • Procedural 98%
    • Financial 98.5%
  • Demonstrates a thorough knowledge of the Plan’s published claims processing procedures on the company’s intranet.
  • Proficient with core applications of the current claims processing system and front-end messaging
  • Promptly review and apply appropriate pricing to claims that require manual review using methods that reside outside of the claims processing system as assigned.
  • Analyze service forms and respond promptly and/or route to appropriate area for review of the pended claims less than or equal to 30 days
  • Perform other duties as directed to support the overall functions of the Claims Department
  • Must attend all required claims training / refresher classes
  • Actively participate in shared accountability and commitment for departmental and organizational-wide results. Support departmental/team goals and objective.

General Information/Qualifications:

  • High School Diploma
  • Two to three years’ experience of claims processing in a health insurance environment strongly preferred
  • Two to three years’ experience in customer service; provider unit desirable
  • COB processing and/or investigation methods a plus
  • Demonstrated experience in all lines of business; HMO, PPO, Medicare, Medicaid, etc
  • Knowledge of ICD, CPT, and DRG coding, and medical terminology strongly preferred
  • Ability to prioritize and handle large volumes of work
  • Ability to work in a production environment that can be stressful
  • Maintain a high level of motivation, initiative, and accountability
  • Demonstrated excellent written and oral communication skills
  • Ability to maintain confidential information
  • Maintains respectful and professional behavior

 

ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio.  For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace

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