You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.

Job Summary

Our client is seeking a Claims Adjuster responsible for reviewing and adjudicating various types of claims. The role involves meeting production and quality goals, ensuring all necessary criteria are applied to validate claims, and effectively managing pending claims and correspondence.

Key Responsibilities

• Review and adjudicate production claims while meeting production and quality goals.
• Investigate claims and apply necessary criteria to determine their validity.
• Understand and apply Anthem JAA workflow and processing procedures to adjudicate claims.
• Apply benefit plan rules and guidelines to pay, pend, or deny claims.
• Track pending claims and correspondence, including reviewing patient claim history.
• Generate accurate claim EOB messages and correspondence.
• Determine eligibility and coverage for specific group/plan.
• Resolve claim problems by taking necessary actions.
• Utilize training and documentation to stay updated on processing guidelines and regulations.
• Update claims system with relevant notes.
• Conduct investigations for COB, No-fault, Pre-existing, and other claims.
• Contact employers, providers, and participants as needed.
• Identify correct providers, PPOs, and ensure proper pricing is obtained.
• Perform claim adjustments and handle customer service referrals as needed.
• Troubleshoot utilization review and medical necessity issues using vendor information.
• Use Claim Workflow system for assignments, routing, and follow-up.
• Manage additional claim-related duties, projects, and assignments.

Qualifications

• One to two years of college or equivalent experience.
• Medical billing and/or AMA coding experience preferred.
• Data Entry experience or equivalent type work using keyboard/PC.
• Requires NYS Accident & Health Adjuster License

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

Required Employment / Compliance Language

To apply for this position, please note that eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, coverage will begin based on your plan selection(s).

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.

^*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients