Claims Adjudicator III

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The purpose of the Claims Adjudicator III position is to successfully collaborate with the team Supervisor to provide direction and support to the team. This involves adjudicating complex medical, vision, dental, and short\-term disability claims, as well as, escalated member and provider inquiries within established timeframes. The Claims Adjudicator Level III ensures claims are processed accurately according to the benefits as defined in the various Plan Documents. This position supports the team Supervisor in meeting departmental inventory metrics based on guidelines set forth by the Claims Department Management Team and the Department of Labor. The position is responsible for partnering with the PPO vendors to ensure that the financial responsibilities are met, which includes, but is not limited to the BlueCross and BlueShield incentive and daily claim rejects. This individual must possess excellent communication and organizational skills and can work independently. This position is relied upon as a subject matter expert for the Plan Documents and benefits for all Plan units managed by Aurora and associated regional offices. This position provides development and coaching to peers to ensure a high service quality. ESSENTIAL JOB FUNCTIONS AND DUTIES

• Successfully investigate and respond to escalated inquiries from internal and external sources
• Interacts with vendors and other UHH operational areas to resolve complex issues
• Analyzes problems, identifies and develops alternative solutions, and implements recommendations
• Triages claims and inquiries to determine if additional information or documentation from members, employers, providers and other insurance carriers is required
• Verifies participant/dependent eligibility utilizing multiple internal systems
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents to ensure accuracy
• Responsible for comprehensive research and end to end processing of Medicare Secondary Payer (MSP) files, Personal Injury Protection (PIP) claims, Short Term Disability claims, Subrogation files, and complex claim adjustments
• Requests overpayment refunds, maintains corresponding files and performs follow\-up actions
• Handles verbal and written inquiries received from internal and external customers
• Identifies areas for process improvement and makes recommendations to management
• Coordinates with team Senior and Supervisor to lead individual and/or team training sessions
• Demonstrate necessary competence in technical, industry standard and soft skills to effectively support team
• Acts as a subject matter expert providing support and mentoring to peers
• Partners with other departmental areas on new and updated processes
• Adjudicates claims and complex inqiuries according to established productivity and quality goals
• Achieve individual established goals in order to meet or exceed departmental metrics
• Set goals and achieve measurable results
• Contributes ideas to plans and achieving department goals
• Exemplifies the Fund’s BETTER Values and Professional Effectiveness Dimensions in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation

ESSENTIAL QUALIFICATIONSYears of Experience and Knowledge

• 4 \~ 6 years of direct experience in a medical claim adjudication environment
• Experience with interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Working knowledge of plan design documents and pricing methodologies
• Working knowledge and experience in medical claims adjudication, preferably in a multi\-employer environment
• Understanding of Medicare, Medicaid, ACA, DOL regulations, ERISA and HIPAA

Education, Licenses, and Certifications

• High School Diploma or GED
• College degree preferred or equivalent work experience required

Skills and Abilities

• Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook) required
• Intermediate level Microsoft Excel skills
• Manage competing deadlines and multiple projects in a fast\-paced environment
• Excellent communication skills (verbal and written) required
• Exceptional time management, organizational and problem\-solving skills
• Ability to demonstrate good judgment and have excellent critical thinking skills
• Ability to work independently with minimal supervision in a fast\-paced environment

OTHER JOB FUNCTIONS AND DUTIES

The information contained in this job description is designed to indicate the general nature and level of work performed in this job with a certain degree of specificity, where warranted. In no instance, however, should the duties, functions, qualifications, or requirements be interpreted as all\-inclusive. Management may, at its discretion, assign or reassign functions and duties to or from this job at any time, due to reasonable accommodation or other reasons. Listed requirements, skills, qualifications and abilities included have been determined to illustrate the minimal standards required to successfully perform the position. Salary range for this position: Hourly rate $23\.7949 \- $29\.1282\. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location. Work Schedule (may vary to meet business needs): Monday\~Friday, 7\.5 hours per day (37\.5 hours per week) with potential for hybrid work\-from\-home arrangement. We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time\-Off (PTO), Paid Holidays, 401(k), Short\- \& Long\-term Disability, Pension, Life, AD\&D, Flexible Spending Accounts (healthcare \& dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

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