Resolutions/ Adjustment Clerk

Job description

Job Description: The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs.

Responsiblities:
· Participates productively as a member of a team.
· Completes tasks beyond general support level.
· Accepts instruction and direction from leadership. Ability to manage tasks and assignments without detailed direction.
· Identifies, prioritizes and resolves some issues independently, and escalates more complex questions or issues appropriately.
· Complies with contract requirements, business unit rules and related and legal regulations

Desired profile

Education and Experience :

·  High School Diploma or equivalent; may hold 2 year post-high school Degree; may hold Bachelor's degree.
·  Typically, 1-2 years of working experience in related fields.

Knowledge and Skills:

·  Prior office or clerical experience.
·  Ability to follow written policies and procedures.
·  Ability to access and retrieve information using a PC and basic understanding of Microsoft Office products.
·  Ability to follow procedural guidelines.'
·  Ability to work on assignments with limited instructions from leadership.
·  Good written and verbal communication skills, including professional telephone skills.