Claims Adjudicator

Under the general supervision of the Director of Claims, the Claims Adjudicator is responsible for reviewing all claims submitted to DWIHN and paying or denying claims after they are evaluated. Claims adjudicators are also responsible for determining the amount of money that should be paid as well as deciding if the claim should be denied.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Reviews all claims submitted to DWIHN.
• Completes billing on Faxed claims.
• Determines whether claims should be paid or denied after they are evaluated.
• Determines the payment amount.
• Decides if claims should be denied based on error messages.
• Adjudicates claims and identifies according to funding source.
• Makes corrections as necessary to ensure proper processing.
• Processes claims and rejections entered via IT System.
• Processes appeals on rejection/denial of claims.
• Troubleshoots billing rejections.
• Verifies client insurance, designation, and demographic information before claim is adjudicated.
• Ensure approved authorizations are attached to the claims.
• Establishes open communication with providers to support the processing of claims.
• Trains and assists providers in the claims processing process.
• Evaluates and processes claims in accordance with company policies and procedures.
• Assists providers, and clients with problems or questions regarding their claims and/or policies.
• Opens and processes mail.
• Completes claim projects as assigned.
• Authorizes payment of valid claims.
• Interprets medical and billing coding according to the State FY Behavioral Health Code Charts & Provider Qualifications.
• Performs related duties as assigned.

KNOWLEDGES, SKILLS AND ABILITIES (KSA'S)

• Assessment skills.
• Accuracy skills.
• Attention to detail skills.
• Analytical skills.
• Problem Solving skills.
• Customer Service skills.
• Teaching skills.
• Training skills.
• Computer skills (Word, Excel, Access, Power Point, Outlook, Teams)
• Teamwork Skills.
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically, and socially diverse population.
• Judgement/Reasoning ability.

REQUIRED EDUCATION:

A High School Diploma, GED or equivalent.

REQUIRED EXPERIENCE:

Two (2) years of full-time paid professional experience performing claims processing or medical billing.

REQUIRED LICENSE(S).

A valid State of Michigan Driver's License with a safe and acceptable driving record.

WORKING CONDITIONS:

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. Currently this position is primarily a remote position.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time.

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer